Predictive value of prenatal ultrasound combined with long non-coding RNA CRNDE of women for their postpartum lower extremity deep venous thrombosis

OBJECTIVE

Deep vein thrombosis (DVT) is a common complication in obstetrics that needs early interaction. The study examined the expression change and clinical value of long non-coding RNA (lncRNA) colorectal neoplasia differentially expressed (CRNDE) in DVT early diagnosis.

METHODS

One hundred patients with DVT after delivery and 100 healthy parturients without DVT were enrolled. Serum samples were collected one day before delivery and received qRT-PCR for mRNA detection. Prenatal coagulation markers including prothrombin time (PT), activated partial prothrombin time (APTT), fibrinogen (FIB) and thrombin time (TT), D-dimer (D-D), thrombomodulin (TM), and peroxidase anti-peroxidase soluble complex (PAP) were tested. The receiver operating characteristic (ROC) curve was drawn for the diagnostic value assessment.

RESULTS

LncRNA CRNDE levels increased remarkably in the serum of DVT patients compared with the healthy controls, which were negatively correlated with serum concentration of PT, APTT, and TT while positively correlated with FIB, D-D, TM, and PAP. Serum CRNDE (HR = 5.973, 95% CI = 2.990-11.933, p < .001) was independently related to the occurrence of DVT after delivery. Then, ROC curve using serum CRNDE showed a good diagnostic value for DVT with the AUC of 0.899. ROC curve of ultrasonography combined with CRNDE produced an AUC of 0.968, and both sensitivity and specificity were enhanced compared to a single indicator.

CONCLUSIONS

The increase of CRNDE level was an independent risk factor for postpartum DVT. Prenatal ultrasonography combined with CRNDE can improve the predictive efficacy for DVT.

Lower limb blood flow occlusion increases systemic pressor response without increasing brachial arterial blood flow redistribution in women

This study was conducted to investigate the systemic hemodynamic and vascular changes in women during and after two commonly used clinical blood flow restriction (BFR) pressures at rest. There are minimal data regarding the independent effects of BFR on hemodynamic and systemic vascular changes due to pressor response, particularly among women. Therefore, this study investigated BFR-induced alterations in pressor response and systemic flow redistribution at rest during two commonly used pressures (50% and 80% limb occlusion pressure [LOP]). Fifteen women (22.1 ± 4.2 years) completed two randomised sessions involving 8-min of bilateral, lower limb restriction at 50% or 80% LOP followed by 8-min of recovery post-deflation. Changes in vascular (arterial diameter [DIA], time-averaged mean velocity [TAMV], volume flow [VF], and area) and hemodynamic (heart rate [HR] and blood pressure) measures over time (pre-, during, post-occlusion) and by session (50% vs. 80% LOP) were tested using repeated measures analysis of variance. Repeated measures correlations (rrm) quantified common intraindividual associations between BFR-induced hemodynamic and vascular responses. HR increased from baseline during 50% LOP and remained elevated during recovery (p < 0.05). HR increased from baseline during 80% LOP, while tibial VF and TAMV decreased (p < 0.03 for all). HR and TAMV values returned to baseline during recovery, while brachial artery VF decreased (p < 0.05). Changes in HR, brachial VF, and brachial TAMV were similar between 50% and 80% LOP (rrm = 0.32-0.70, p < 0.05 for all). At 80% LOP, changes in HR were positively correlated with brachial VF (rrm = 0.38) and TAMV (rrm = 0.43) and negatively correlated with tibial VF (rrm = -0.36) and TAMV (rrm = -0.30) (p < 0.05 for all). Results suggest that BFR at 80% LOP elicits an acute systemic pressor reflex without concomitant increases in brachial arterial flow, while 50% LOP elicits a subdued response.

Development and validation of a risk prediction model and prediction tools for post-thrombotic syndrome in patients with lower limb deep vein thrombosis

PURPOSE

Our research aims to compare the predictive performance of decision tree algorithms (DT) and logistic regression analysis (LR) in constructing models, and develop a Post-Thrombotic Syndrome (PTS) risk stratification tool.

METHODS

We retrospectively collected and analyzed relevant case information of 618 patients diagnosed with DVT from January 2012 to December 2021 in three different tertiary hospitals in Jiangxi Province as the modeling group. Additionally, we used the case information of 212 patients diagnosed with DVT from January 2022 to January 2023 in two tertiary hospitals in Hubei Province and Guangdong Province as the validation group. We extracted electronic medical record information including general patient data, medical history, laboratory test indicators, and treatment data for analysis. We established DT and LR models and compared their predictive performance using receiver operating characteristic (ROC) curves and confusion matrices. Internal and external validations were conducted. Additionally, we utilized LR to generate nomogram charts, calibration curves, and decision curves analysis (DCA) to assess its predictive accuracy.

RESULTS

Both DT and LR models indicate that Year, Residence, Cancer, Varicose Vein Operation History, DM, and Chronic VTE are risk factors for PTS occurrence. In internal validation, DT outperforms LR (0.962 vs 0.925, z = 3.379, P < 0.001). However, in external validation, there is no significant difference in the area under the ROC curve between the two models (0.963 vs 0.949, z = 0.412, P = 0.680). The validation results of calibration curves and DCA demonstrate that LR exhibits good predictive accuracy and clinical effectiveness. A web-based calculator software of nomogram (https://sunxiaoxuan.shinyapps.io/dynnomapp/) was utilized to visualize the logistic regression model.

CONCLUSIONS

The combination of decision tree and logistic regression models, along with the web-based calculator software of nomogram, can assist healthcare professionals in accurately assessing the risk of PTS occurrence in individual patients with lower limb DVT.

Single Center Outcomes of Percutaneous Deep Vein Arterialization in Patients with End-Stage Peripheral Artery Disease

Background: Peripheral artery disease (PAD) can present as chronic limb threatening ischemia (CLTI) with ischemic pain and tissue loss. Progression of distal disease can lead to a "no option" or end-stage disease without traditional open or endovascular revascularization due to lack of pedal targets. Innovations in endovascular technology allow for the use of percutaneous deep vein arterialization (pDVA) to treat patients with CLTI. Purpose: We describe our experience and technique for treating four patients with end-stage PAD with pDVA. Research Design: Four patients with end-stage PAD were followed during and after pDVA creation. Technical success, complications, wound healing, and freedom from major amputation were analyzed. Data Collection and Analysis: Patient data and outcomes were collected via chart review and at time of follow up appointments in vascular surgery clinic. Results: Technical success was 100%, without post-procedural complications, and patients were continued on antiplatelet and anticoagulation. Three patients (75%) had successful wound healing, with 2 patients healing after transmetatarsal amputation (TMA), and 1 healing a distal foot ulceration that did not require surgery. One patient had worsening ischemic breakdown of a TMA, despite re-intervention on the pDVA, which required a below knee amputation (BKA). Freedom from major amputation was 75% overall, with an average follow-up time of 410 days post-procedure (Range: 113-563 days). Conclusions: Percutaneous deep vein arterialization attempts to provide blood flow to the preserved venous bed in patients with end-stage PAD. Exploration and utilization of this technique continues to expand in the modern vascular era. This case series highlights 4 patients with end-stage PVD who underwent pDVA, with 100% procedural success, and 75% limb salvage rate.

Turbo spin-echo-based enhanced acceleration-selective arterial spin labeling without electrocardiography or peripheral pulse unit triggering and contrast enhancement for lower extremity MRA

PURPOSE

Lower extremity magnetic resonance angiography (MRA) without electrocardiography (ECG) or peripheral pulse unit (PPU) triggering and contrast enhancement is beneficial for diagnosing peripheral arterial disease (PAD) while avoiding synchronization failure and nephrogenic systemic fibrosis. This study aimed to compare the diagnostic performance of turbo spin-echo-based enhanced acceleration-selective arterial spin labeling (eAccASL) (TSE-Acc) of the lower extremities with that of turbo field-echo-based eAccASL (TFE-Acc) and triggered angiography non-contrast enhanced (TRANCE).

METHODS

Nine healthy volunteers and a patient with PAD were examined on a 3.0 Tesla magnetic resonance imaging (MRI) system. The artery-to-muscle signal intensity ratio (SIR) and contrast-to-noise ratio (CNR) were calculated. The arterial visibility (1: poor, 4: excellent) and artifact contamination (1: severe, 4: no) were independently assessed by two radiologists. Phase-contrast MRI and digital subtraction angiography were referenced in a patient with PAD. Friedman's test and a post-hoc test according to the Bonferroni-adjusted Wilcoxon signed-rank test were used for the SIR, CNR, and visual assessment. p < 0.05 was considered statistically significant.

RESULTS

No significant differences in nearly all the SIRs were observed among the three MRA methods. Higher CNRs were observed with TSE-Acc than those with TFE-Acc (anterior tibial artery, p = 0.014; peroneal artery, p = 0.029; and posterior tibial artery, p = 0.014) in distal arterial segments; however, no significant differences were observed upon comparison with TRANCE (all p > 0.05). The arterial visibility scores exhibited similar trends as the CNRs. The artifact contamination scores with TSE-Acc were significantly lower (but within an acceptable level) compared to those with TFE-Acc. In the patient with PAD, the sluggish peripheral arteries were better visualized using TSE-Acc than those using TFE-Acc, and the collateral and stenosis arteries were better visualized using TSE-Acc than those using TRANCE.

CONCLUSION

Peripheral arterial visualization was better with TSE-Acc than that with TFE-Acc in lower extremity MRA without ECG or PPU triggering and contrast enhancement, which was comparable with TRANCE as the reference standard. Furthermore, TSE-Acc may propose satisfactory diagnostic performance for diagnosing PAD in patients with arrhythmia and chronic kidney disease.

Comparative Study of Small Vessel (under 0.8 mm) Anastomosed Free Flap and Larger Vessel (over 0.8 mm) Anastomosed Free Flap: Does Supermicrosurgery Provide Sufficient Blood Flow to the Free Flap?

BACKGROUND

 This study aimed to quantify the blood flow of free flaps and compare the blood flow of small vessel (<0.8 mm) and larger vessel (>0.8 mm) anastomosed free flaps.

METHODS

 This retrospective study included patients treated successfully with a perforator free flap in the lower extremity between June 2015 and March 2017. A color duplex ultrasound system measured the flow volume through the pedicle by analyzing the mean flow peak velocity, flow volume, and flow volume per 100 g of the flap.

RESULTS

 A total of 69 patients were enrolled in this study. There was no statistical difference in peak velocity between the small vessel anastomosed free flap (25.2 ± 5.6) and larger vessel anastomosed free flap (26.5 ± 5.4). Flow volume (6.8 ± 4.2 vs. 6.3 ± 3.6) and flow volume/100 g (3.6 ± 3.9 vs. 6.2 ± 6.9) also did not show significant differences.

CONCLUSION

 Small vessel (<0.8 mm) free flaps showed similar flow velocity and flow volume to larger vessel (>0.8 mm) anastomosed free flaps. Blood flow to the small vessel anastomosed free flap was sufficient despite its small vessel size.

Blood Flow Restriction and Veterans With Multiple Sclerosis and Advanced Disability: Protocol for a Randomized Controlled Trial

OBJECTIVE

The purpose of this study will be to determine the efficacy of low intensity lower extremity resistance training with and without blood flow restriction (BFR) on quadriceps muscle strength and thickness in veterans with advanced multiple sclerosis (MS).

METHODS

This will be an assessor-blinded, 2-group (1 to 1 allocation) randomized controlled trial targeting an enrollment of 58 participants with advanced MS as defined by Patient-Determined Disease Steps scale levels 4 to 7. Both groups will complete 10 weeks of twice weekly low-load resistance training (20%-30% of 1-repetition max) targeting knee and hip extension, knee flexion, and ankle plantarflexion. The intervention group will perform all training using BFR, with limb occlusion pressures between 60% and 80% of maximal limb occlusion pressure. Primary outcomes will be quadriceps muscle strength and thickness. Secondary outcomes will include knee flexion and ankle plantarflexion strength, functional mobility, physical activity, and patient-reported measures. All outcomes will be assessed at baseline before the intervention, immediately after the intervention, and at a 2-month follow-up assessment. The change between groups postintervention and after the 2-month follow-up will be reported for all outcomes. All analyses will assume a 2-sided test of hypothesis (α = .05).

IMPACT

There is very little evidence for the efficacy of exercise interventions in people with MS who have advanced mobility disability. Resistance training with BFR may be an important approach for people with advanced MS who may not tolerate more conventional, moderate-to-high intensity resistance training. The results of this study will inform clinicians regarding exercise decisions for people with advanced MS and future investigations on the role of BFR in people with MS.

Modelling lower-limb peripheral arterial disease using clinically available datasets: impact of inflow boundary conditions on hemodynamic indices for restenosis prediction

BACKGROUND AND OBJECTIVES

The integration of hemodynamic markers as risk factors in restenosis prediction models for lower-limb peripheral arteries is hindered by fragmented clinical datasets. Computed tomography (CT) scans enable vessel geometry reconstruction and can be obtained at different times than the Doppler ultrasound (DUS) images, which provide information on blood flow velocity. Computational fluid dynamics (CFD) simulations allow the computation of near-wall hemodynamic indices, whose accuracy depends on the prescribed inlet boundary condition (BC), derived from the DUS images. This study aims to: (i) investigate the impact of different DUS-derived velocity waveforms on CFD results; (ii) test whether the same vessel areas, subjected to altered hemodynamics, can be detected independently of the applied inlet BC; (iii) suggest suitable DUS images to obtain reliable CFD results.

METHODS

CFD simulations were conducted on three patients treated with bypass surgery, using patient-specific DUS-derived inlet BCs recorded at either the same or different time points than the CT scan. The impact of the chosen inflow condition on bypass hemodynamics was assessed in terms of wall shear stress (WSS)-derived quantities. Patient-specific critical thresholds for the hemodynamic indices were applied to identify critical luminal areas and compare the results with a reference obtained with a DUS image acquired in close temporal proximity to the CT scan.

RESULTS

The main findings indicate that: (i) DUS-derived inlet velocity waveforms acquired at different time points than the CT scan led to statistically significantly different CFD results (p<0.001); (ii) the same luminal surface areas, exposed to low time-averaged WSS, could be identified independently of the applied inlet BCs; (iii) similar outcomes were observed for the other hemodynamic indices if the prescribed inlet velocity waveform had the same shape and comparable systolic acceleration time to the one recorded in close temporal proximity to the CT scan.

CONCLUSIONS

Despite a lack of standardised data collection for diseased lower-limb peripheral arteries, an accurate estimation of luminal areas subjected to altered near-wall hemodynamics is possible independently of the applied inlet BC. This holds if the applied inlet waveform shares some characteristics - derivable from the DUS report - as one matching the acquisition time of the CT scan.

Extracorporeal Membrane Oxygenation-Associated Compartment Syndrome: Review of a National Database

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO)-associated compartment syndrome (CS) is a rare complication seen in critically ill patients. The epidemiology and management of ECMO-associated CS in the upper extremity (UE) and lower extremity (LE) are poorly defined in the literature. We sought to determine the epidemiology and characterize treatment and outcomes of UE-CS compared to LE-CS in the setting of ECMO therapy.

METHODS

Adult patients undergoing ECMO therapy were identified in the Nationwide Readmission Database (2015-2019) and followed up for 6 months. Patients were stratified based on UE-CS versus LE-CS. Primary outcomes were fasciotomy and amputation. All-cause mortality and length of stay were also collected. Risk-adjusted modeling was performed to determine patient- and hospital-level factors associated with differences in the management UE-CS versus LE-CS while controlling for confounders.

RESULTS

A total of 24,047 cases of ECMO during hospitalization were identified of which 598 were complicated by CS. Of this population, 507 cases were in the LE (84.8%), while 91 (15.5%) were in the UE. After multivariate analysis, UE-CS patients were less likely to undergo fasciotomy (50.5 vs. 70.9; P = 0.013) and were less likely to undergo amputation of the extremity (3.3 vs. 23.7; P = 0.001) although there was no difference in mortality (58.4 vs. 65.4; P = 0.330).

CONCLUSIONS

ECMO patients with CS experience high mortality and morbidity. UE-CS has lower rates of fasciotomy and amputations, compared to LE-CS, with similar mortality. Further studies are needed to elucidate the reasons for these differences.

Five-Week, Low-Intensity Blood Flow Restriction Rowing Improves V̇ o2 max in Elite Rowers

ABSTRACT

Held, S, Rappelt, L, Rein, R, Deutsch, J-P, Wiedenmann, T, and Donath, L. Five-week, low-intensity, blood flow restriction rowing improves V̇ o2 max in elite rowers. J Strength Cond Res 38(6): e299-e303, 2024-This controlled intervention study examined the effects of low-intensity rowing with blood flow restriction (BFR) on maximal oxygen uptake (V̇ o2 max), peak power output during ramp testing (PPO), and 2000-m time trial performance (P2k). Eleven, highly elite, male rowers (22.1 ± 1.6 years; 92.6 ± 3.8 kg; 1.93 ± 0.04 m; 7.9. ± 2.2 years rowing experience; 20.4 ± 2.0 h·w -1 training volume; 11.9 ± 1.1 session per week) trained 5 weeks without BFR (Base) followed by a 5-week BFR intervention period. BFR of the lower limb was applied through customized elastic wraps. BFR took place 3 times a week (accumulated net pBFR: 60 min·wk -1 ; occlusion per session: 2 times 10 min·session -1 ) and was used exclusively at low intensities (<2 mmol·L -1 ). V̇ o2 max, PPO, and P2k were examined before, between, and after both intervention periods. Bayesian's credible intervals revealed relevantly increased V̇ o2 max +0.30 L·min -1 (95% credible interval: +0.00 to +0.61 L·min -1 ) adaptations through BFR. By contrast, PPO +14 W (-6 to +34 W) and P2k -5 W (-14 to +3 W) were not noticeably affected by the BFR intervention. This study revealed that 15 sessions of BFR application with a cumulative total BFR load of 5 h over a 5-week macrocycle increased V̇ o2 max remarkably. Thus, pBFR might serve as a promising tool to improve aerobic capacity in highly trained elite rowers.

The inpatient costs related to revascularization of lower extremity artery disease in terms of amputation and mortality rates

OBJECTIVE

With the initial utilization of endovascular treatment options in 1970s, the number of procedures performed for lower extremity artery disease (LEAD) both with open surgical (OS) and endovascular (EV) treatment increased, but this did not result in a decrease in the number of amputations. The burden of LEAD still constitutes a huge proportion among the health care costs over the world.

METHODS

The patients who admitted to our clinic between October 2014 and December 2019 with LEAD and required revascularization were enrolled. The total hospitalization costs related to LEAD were registered and divided into two groups as care costs and medical supplies costs.

RESULTS

181 procedures were performed to 133 patients. Mean age was 63.98 ± 11.65 and 115 (86.5%) patients were male. Mean follow-up period was 31.19 ± 17.99 months (95% CI). The most frequent comorbidities were diabetes mellitus (DM) (n = 86, 66.2%) and active smoking (n = 59, 44.4%). Total costs and medical supplies costs were increased in EV group when compared with OS group ($4347.26 ± 3352.96, $3339.28 ± 3459.53 p = .005 v.s. $3318.67 ± 2874.55,$904.42 ± 1209.97 p < .001, respectively). Care costs were increased in OS group when compared with EV group ($2434.85 ± 2641.89 v.s. $1028.56 ± 1397.77 p < .001). The highest total, medical supplies, and care costs were determined in EV + OS group ($13071.32 ± 13717; $6784.91 ± 8332.04; $6286.41 ± 7652.12, respectively).Graft/wound infection related and amputation related costs were 21% of all costs. Amputation-free survival was 71.42% (95% CI) with 21 total amputations. There were linear correlations between mortality and amputation (p = .002); also between mortality and cost (p = .001).

CONCLUSIONS

In mid-long-term period, the care costs are increased with OS; however, EV treatment significantly increases the medical supplies and total costs. The increase in cost is correlated with poor outcome. Although the comorbidities and risk factors of these patients lead the clinicians to perform more challenging endovascular approaches, in mid-long-term period, particularly failed endovascular procedures are not promising in terms of outcomes and costs. We consider that the best-fit therapy on time is cost-effective, life and extremity-saving either, by avoiding deleterious effects of severe ischemia, such as severe pain, tissue loss, and related major adverse cardiaovascular events.

Long-term outcomes of autologous vein bypass for repair of upper and lower extremity major arterial trauma

OBJECTIVE

Autologous vein is the preferred bypass conduit for extremity arterial injuries owing to superior patency and low infection risk; however, long-term data on outcomes in civilians are limited. Our goal was to assess short- and long-term outcomes of autologous vein bypass for upper and lower extremity arterial trauma.

METHODS

A retrospective review was performed of patients with major extremity arterial injuries (2001-2019) at a level I trauma center. Demographics, injury and intervention details, and outcomes were recorded. Primary outcomes were primary patency at 1 year and 3 years. Secondary outcomes were limb function at 6 months, major amputation, and mortality. Multivariable analysis determined risk factors for functional impairment.

RESULTS

There were 107 extremity arterial injuries (31.8% upper and 68.2% lower) treated with autologous vein bypass. Mechanism was penetrating in 77% of cases, of which 79.3% were due to firearms. The most frequently injured vessels were the common and superficial femoral (38%), popliteal (30%), and brachial arteries (29%). For upper extremity trauma, concomitant nerve and orthopedic injuries were found in 15 (44.1%) and 11 (32.4%) cases, respectively. For lower extremities, concomitant nerve injuries were found in 10 (13.7%) cases, and orthopedic injuries in 31 (42.5%). Great saphenous vein was the conduit in 96% of cases. Immediate intraoperative bypass revision occurred in 9.3% of patients, most commonly for graft thrombosis. The in-hospital return to operating room rate was 15.9%, with graft thrombosis (47.1%) and wound infections (23.5%) being the most common reasons. The median follow-up was 3.6 years. Kaplan-Meier analysis showed 92% primary patency at 1 year and 90% at 3 years. At 6 months, 36.1% of patients had functional impairment. Of patients with functional impairment at 6 months, 62.9% had concomitant nerve and 60% concomitant orthopedic injuries. Of those with nerve injury, 91.7% had functional impairment, compared with 17.8% without nerve injury (P < .001). Of patients with orthopedic injuries, 51.2% had functional impairment, vs 25% of those without orthopedic injuries (P = .01). On multivariable analysis, concomitant nerve injury (odds ratio, 127.4; 95% confidence interval, 17-957; P <. 001) and immediate intraoperative revision (odds ratio, 11.03; 95% confidence interval, 1.27-95.55; P = .029) were associated with functional impairment.

CONCLUSIONS

Autologous vein bypass for major extremity arterial trauma is durable; however, many patients have long-term limb dysfunction associated with concomitant nerve injury and immediate intraoperative bypass revision. These factors may allow clinicians to identify patients at higher risk for functional impairment, to outline patient expectations and direct rehabilitation efforts toward improving functional outcomes.

Effect of veno-arterial extracorporeal membrane oxygenation lower-extremity cannulation on intra-arterial flow characteristics, oxygen content, and thrombosis risk

PURPOSE

This study aimed to investigate the effects of lower-extremity cannulation on the intra-arterial hemodynamic environment, oxygen content, blood damage, and thrombosis risk under different levels of veno-arterial (V-A) ECMO support.

METHODS

Computational fluid dynamics methods were used to investigate the effects of different levels of ECMO support (ECMO flow ratios supplying oxygen-rich blood 100-40 %). Flow rates and oxygen content in each arterial branch were used to determine organ perfusion. A new thrombosis model considering platelet activation and deposition was proposed to determine the platelet activation and thrombosis risk at different levels of ECMO support. A red blood cell damage model was used to explore the risk of hemolysis.

RESULTS

Our study found that partial recovery of cardiac function improved the intra-arterial hemodynamic environment, with reduced impingement of the intra-arterial flow field by high-velocity blood flow from the cannula, a flow rate per unit time into each arterial branch closer to physiological levels, and improved perfusion in the lower extremities. Partial recovery of cardiac function helps reduce intra-arterial high shear stress and residence time, thereby reducing blood damage. The overall level of hemolysis and platelet activation in the aorta decreased with the gradual recovery of cardiac contraction function. The areas at high risk of thrombosis under V-A ECMO femoral cannulation support were the aortic root and the area distal to the cannula, which moved to the descending aorta when cardiac function recovered to 40-60 %. However, with the recovery of cardiac contraction function, hypoxic blood pumped by the heart is insufficient in supplying oxygen to the front of the aortic arch, which may result in upper extremity hypoxia.

CONCLUSION

We developed a thrombosis risk prediction model applicable to ECMO cannulation and validated the model accuracy using clinical data. Partial recovery of cardiac function contributed to an improvement in the aortic hemodynamic environment and a reduction in the risk of blood damage; however, there is a potential risk of insufficient perfusion of oxygen-rich blood to organs.

Growth Differentiation Factor-15 and Clinical Outcomes in Lower Extremity Artery Disease

AIM

Lower extremity artery disease (LEAD) is an increasingly common health problem that is associated with high mortality due to thrombotic and bleeding events. Growth differentiation factor-15 (GDF15), a stress-response cytokine belonging to the transforming growth factor-beta superfamily, is associated with cardiovascular disease and its outcomes. The aim of the present study was to examine the effect of serum GDF15 levels on clinical outcomes in patients with LEAD.

METHODS

We measured serum GDF15 levels in 200 patients with LEAD before their initial endovascular therapy. The primary endpoint was the all-cause mortality rate. The secondary endpoints, on the other hand, were thrombotic and bleeding events, such as cerebral infarction, acute coronary syndrome, acute limb ischemia, and Bleeding Academic Research Consortium types 3 and 5.

RESULTS

The serum GDF15 levels increased with advancing Fontaine class. Kaplan-Meier analysis revealed that the high-GDF15 group (≥ 2,275 pg/mL) had higher rates of all-cause deaths and thrombotic and bleeding events than the low-GDF15 group (＜2,275 pg/mL). Multivariate Cox proportional-hazards regression analysis revealed that GDF15 was an independent predictor of all-cause mortality and thrombotic and bleeding events after adjusting for confounding risk factors. When the ABC-AF-bleeding score was substituted for GDF15, similar results were obtained.

CONCLUSION

Serum GDF15 levels were associated with all-cause mortality and thrombotic and bleeding events in patients with LEAD. Serum GDF15 is a potentially useful marker of clinical outcomes, specifically for tracking thrombotic and bleeding events in patients with LEAD.

Left common iliac vein diameter in patients referred for lower limb venous duplex ultrasound

INTRODUCTION

Evidence regarding ultrasound assessment of left common iliac vein diameter (LCIV) is limited. Extensive work is currently being undertaken worldwide on non-thrombotic iliac vein lesions to identify patients who may benefit from intervention to alleviate symptoms of chronic venous obstruction. Interventions include long-term stent implantation to improve vein diameter stenosis. This study aimed to assess a cohort of symptomatic venous patients and the diameter of the LCIV in these patients.

METHODS

: Retrospective medical records review of all patients attending a tertiary vascular surgery centre who underwent a venous duplex ultrasound assessment between April 2017 and February 2018 were analysed for assessment of LCIV. Medical records of those patients with documented LCIV diameter were assessed over 18 months of follow-up.

RESULTS

: A total of 672 (271 males, 401 females) LCIV diameter measurements were collected. The age of the patients ranged from 21 to 95 years (mean = 56.38). Median LCIV diameter overall was 7.64 mm (IQR 5.80mm-9.00 mm). 40 patients (6%) were reported to have a LCIV diameter measurement of < 4 mm, 8 (20%) male and 32 female (80%). 17 of these 40 patients (47.5%) were treated conservatively. Median LCIV diameter was 3.4 mm (IQR 2.5-3.7). 21 of these 40 patients (52.5%) underwent superficial venous intervention only, with a median LCIV diameter of 3.5 mm (IQR 3.2-3.7) and 2 out of these 40 patients (5%) underwent deep venous stenting (2/2 female - 100%), with a median LCIV diameter of 2.9 (IQR 2.9-2.9). No patients underwent both superficial and deep venous treatment in this 40 patient cohort. In those undergoing superficial venous intervention, 4 (19%) underwent repeat treatment. The two deep venous stenting patients underwent magnetic resonance venogram and venogram with intravascular ultrasound to allow stent placement, which confirmed a narrowed left common iliac vein. Primary stent patency at 18 months was 100%.

CONCLUSION

In this large study cohort of venous duplex assessments the median vein diameter was 7.64 mm and 40 patients out of 672 had a vein diameter smaller than 4 mm. 2 patients underwent deep venous stenting with primary patency of 100%.

Embolization of a duplicated femoral vein for treatment of lower extremity deep venous insufficiency: A case report

BACKGROUND

Lower extremity deep venous insufficiency (DVI) occurs secondary to structural or functional abnormalities of deep venous valves in the affected extremities. The effectiveness of surgical treatment for improvement of the hemodynamic status in these patients remains controversial in clinical practice.

METHOD

In this case report, we describe a patient who presented with severe right lower extremity edema and liposclerosis and underwent venography, which suggested a variation in the number of femoral veins. The valve within the duplicated femoral vein was significantly incompetent; however, the valve of the main trunk of the femoral vein showed normal function. We performed embolization of the duplicated femoral vein.

RESULTS

The patient tolerated the procedure well without recurrent symptoms.

CONCLUSIONS

Individualized assessment based on venography findings is useful to establish the therapeutic approach in patients with DVI.

Technical Aspects of Percutaneous Deep Venous Arterialization Using Off-the-Shelf Devices

PURPOSE

Chronic limb-threatening ischemia (CLTI) represents the clinical end stage of lower extremity peripheral arterial disease (PAD). Although conventional open and endovascular revascularization options are available, some CLTI patients do not respond to these treatments, generally due to small vessel occlusive disease, with only limited or no clinical improvement achieved. This article aims to provide insights related to pertinent venous anatomy of the leg and below the ankle and a technical review of percutaneous deep venous arterialization (pDVA) creation using commonly-available devices.

TECHNIQUE

For patients with "no-option" CLTI, the risk of major amputation and mortality remains high. Although arterial revascularization remains the optimal treatment of CLTI, some patients with severely-diseased or gracile distal arteries have poor outcome. Deep venous arterialization (DVA), in a subset of patients with tibial anatomy amenable to DVA creation, represents the last-ditch attempt before these patients are deemed to have "no-hope" at limb salvage, and major amputation becomes necessary. Refinement in technique and advancement in device development have been shown to allow pDVA to be created with respectable outcomes for the "no-option" CLTI patient population.

CONCLUSION

The pDVA has garnered increasing interest among endovascular specialists to further understand the anatomical and technical key points of this procedure, and it may yet prove to be a useful addition in the armamentarium in our battle against CLTI.

CLINICAL IMPACT

Percutaneous deep venous arterialisation provides another option in the treatment of challenging "no-option" CLTI patients, and off-the-shelf devices will allow this procedure to be performed in centers where dedicated devices are not available.

Predictors of poor outcomes after lower extremity revascularization for acute limb ischemia

OBJECTIVES

Acute lower extremity ischemia is one of the most common emergencies in vascular surgery and is a cause of considerable morbidity and mortality. The goal of this study was to evaluate outcomes of revascularization for acute lower extremity ischemia and to determine factors associated with perioperative morbidity and mortality.

METHODS

A total of 354 patients underwent urgent revascularization for acute lower extremity ischemia at an academic medical center between 2014 and 2019. A retrospective review of patients' demographics, comorbidities, etiology and severity of limb ischemia, and procedural characteristics was recorded. Outcomes, including postoperative complications, perioperative limb loss, and mortality, were analyzed.

RESULTS

The mean patient age was 69 ± 17 years, and 52% were females. 50% of patients presented with Rutherford Class IIb ischemia. Arterial embolization was the most common cause of limb ischemia, seen in 33% of cases. Open surgical revascularization was performed in 241 (68%) patients, while endovascular and hybrid approaches were utilized in 53 (15%) and 60 (17%) cases, respectively. Postoperative adverse events occurred in 44% of patients, including wound complications (11%), cardiac (5%) and pulmonary (16%) complications, strokes (4%), UTIs (10%), renal failure (14%), bleeding (5%), and compartment syndrome (3%). The rate of unplanned return to the operating room was 21%. Major adverse cardiovascular events were seen in 103 (29%) patients and major adverse limb events were seen in 57 (16%) patients. The median length of stay was 10 days (IQR = 4); 49% patients were discharged to skilled nursing facility and 19% were readmitted within 30 days.The rate of amputation during index admission was 10%, and perioperative mortality was 20%. Gender, tibial runoff, and etiology of limb ischemia were independent predictors of limb loss. Women had lower risk of limb loss than men (OR, 0.11; 95% CI, 0.023, 0.38). Poor tibial runoff (one-vessel or absence of flow below the knee) was a significant predictor of limb loss as compared to three-vessel runoff (OR, 14.92; 95% CI, 1.92, 115.88). Aneurysmal disease (OR, 38.35; 95% CI, 3.54, 42.45) and traumatic injuries (OR, 108.08; 95% CI, 8.21, 159.06) were the strongest predictors of amputation as compared to other etiologies of limb ischemia. Multivariate model identified ESRD (OR, 9.2; 95% CI, 1.8-46.3), degree of ischemia (class IIb or higher vs class IIa; OR, 3.5; 95% CI, 1.2-10.6), and age (OR, 1.5; 95% CI 1.1-2.0 for every 10 years) as independent predictors of perioperative mortality.

CONCLUSIONS

Urgent revascularization for management of acute limb ischemia is associated with high morbidity and mortality. Elderly patients with ESRD presenting with severely threatened limbs have especially high risk of perioperative mortality and may not be ideal candidates for limb salvage.

Curcumol reduces lower limb arteriosclerosis in rats by inhibiting human arterial smooth muscle cell activity

Cardiovascular diseases, particularly those involving arterial stenosis and smooth muscle cell proliferation, pose significant health risks. This study aimed to investigate the therapeutic potential of curcumol in inhibiting platelet-derived growth factor-BB (PDGF-BB)-induced human aortic smooth muscle cell (HASMC) proliferation, migration and autophagy. Using cell viability assays, 5-ethynyl-2'-deoxyuridine (EdU) incorporation assays and Western Blot analyses, we observed that curcumol effectively attenuated PDGF-BB-induced HASMC proliferation and migration in a concentration-dependent manner. Furthermore, curcumol mitigated PDGF-BB-induced autophagy, as evidenced by the downregulation of LC3-II/LC3-I ratio and upregulation of P62. In vivo experiments using an arteriosclerosis obliterans model demonstrated that curcumol treatment significantly ameliorated arterial morphology and reduced stenosis. Additionally, curcumol inhibited the activity of the KLF5/COX2 axis, a key pathway in vascular diseases. These findings suggest that curcumol has the potential to serve as a multi-target therapeutic agent for vascular diseases.

Implications of Single-Vessel Runoff on Long-Term Outcomes of Free Tissue Transfer for Lower Extremity Reconstruction

BACKGROUND

 Patients with complex lower extremity (LE) wounds and single-vessel LE runoff (1-VRO) are often considered for amputation. While more challenging, free tissue transfer (FTT) is a means for limb salvage. This study aims to demonstrate the feasibility of limb salvage with FTT in patients with 1-VRO.

METHODS

 Patients undergoing FTT by a single surgeon between 2011 and 2021 were retrospectively reviewed. Data collected included demographics, wound characteristics, vascular status, and operative details. Patients were divided into cohorts based on 1- versus 3-VRO of tibial vessel inflow. Outcomes of interest included postoperative complications such as flap necrosis, flap success, limb salvage, and ambulatory status.

RESULTS

 A total of 188 patients underwent FTT to LE, with 25 patients (13.3%) having 1-VRO. Patients with 1-VRO had a comparable prevalence of diabetes (56.0% vs. 50.0%, p = 0.569) and end-stage renal disease (8.0% vs. 3.7%, p = 0.319). Osteomyelitis was more common in the 1-VRO group (80.0% vs. 60.1%, p = 0.056). FTT donor sites and flap composition were similar between cohorts. At mean follow-up of 21.2 months (interquartile range 24.5:5.6, 30.1 months), limb salvage rates were similar between cohorts (84.0% vs. 91.4%, p = 0.241), with no significant differences in ambulatory status or mortality. Higher complication rates occurred in the 1-VRO cohort (48.0% vs. 21.5%, p = 0.004), of which partial flap necrosis was more prevalent in the 1-VRO group (8.0% vs. 1.2%, p = 0.029). There was no difference in flap success rates between groups (p = 0.805). More postflap angiograms were performed in the 1-VRO group (32.0% vs. 9.2%, p = 0.001), but there was no difference in need for repeat percutaneous endovascular intervention between groups.

CONCLUSION

 This study demonstrates that FTT reconstruction to the LE remains a reliable reconstruction option for limb salvage in patients with single-vessel supply to the LE. Reliance on advanced perioperative management and patient optimization is effective at reducing negative outcomes.

Neurological Complications of the Lower Extremities After Femoral Cannulated Extracorporeal Membrane Oxygenation: A Systematic Review

BACKGROUND

Femoral cannulated extracorporeal membrane oxygenation (ECMO) has been associated with neurologic complications in the lower extremity ipsilateral to the cannulation. There is uncertainty about the prevalence of these complications and their mechanisms of development.

OBJECTIVE

Aim of this systematic review was to investigate the prevalence of neurological complications after ECMO and to describe possible underlying mechanisms.

METHOD

A systematic literature search was performed in Medline-Ovid, Embase, Cochrane Library, CINAHL, and PEDro until April 2021 for clinical trials in English or German language which quantified neurologic complications in the lower extremity ipsilateral to the ECMO cannulation of adults. The complications had to be delimitable to intensive care unit-acquired weakness. Methodological quality was assessed by 2 independent investigators using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies of the National Heart, Lung, and Blood Institute.

RESULTS

Eight observational studies were included in the synthesis. Study quality was good to fair in 88% of the papers. Overall, 47 of 202 patients (23.3%; ranging from 3% to 48% across studies) with femoral ECMO cannulation showed neurologic complications of the lower extremity ipsilateral to the cannulation. Peripheral ischemia and compression of nerves by the ECMO cannula are discussed as mechanisms of injury.

CONCLUSION

The occurrence of neurological complications after ECMO was common and can lead to long-term impairment. The mechanisms are largely unknown but currently there is no sufficient evidence for the involvement of ECMO. Standardized assessments are needed to systematically screen for neurological complications early after ECMO, to enable countermeasures and prevent further complications.

Traumatic lower extremity amputation as a risk factor for venous thromboembolism

BACKGROUND

This study aimed to evaluate whether lower extremity (LE) amputation among civilian casualties is a risk factor for venous thromboembolism.

METHODS

All patients with severe LE injuries (AIS ≥3) derived from the ACS-TQIP (2013-2020) were divided into those who underwent trauma-associated amputation and those with limb salvage. Propensity score matching was used to mitigate selection bias and confounding and compare the rates of pulmonary embolism (PE) and deep vein thrombosis (DVT).

RESULTS

A total of 145,667 patients with severe LE injuries were included, with 3443 patients requiring LE amputation. After successful matching, patients sustaining LE amputation still experienced significantly higher rates of PE (4.2% vs. 2.5%, p ​< ​0.001) and DVT (6.5% vs. 3.4%, p ​< ​0.001). A sensitivity analysis examining patients with isolated major LE trauma similarly showed a higher rate of thromboembolic complications, including higher incidences of PE (3.2% vs. 2.0%, p ​= ​0.015) and DVT (4.7% vs. 2.6%, p ​< ​0.001).

CONCLUSIONS

In this nationwide analysis, traumatic lower extremity amputation is associated with a significantly higher risk of VTE events, including PE and DVT.

Neutrophil extracellular traps induced by IL-1β promote endothelial dysfunction and aggravate limb ischemia

Vascular inflammation and endothelial dysfunction contribute to vascular diseases. While neutrophil extracellular traps (NETs) participate in some vascular pathologies, their roles in lower limb ischemia remain poorly defined. This study investigated the functional significance of NETs in vascular inflammation and remodeling associated with limb ischemia. Single-cell RNA sequencing (scRNA-seq) and flow cytometry revealed neutrophil activation and upregulated NETs formation in human limb ischemia, with immunofluorescence confirming IL-1β-induced release of NETs for vascular inflammation. Endothelial cell activation was examined via scRNA-seq and western blotting, indicating enhanced proliferation, expression of adhesion molecules (VCAM-1, ICAM-1), inflammatory cytokines (IL-1β, IL-6) and decreased expression of VE-cadherin, that could be mediated by NETs to exacerbate endothelial inflammation. Mechanistically, NETs altered endothelial cell function via increased pSTAT1/STAT1 signaling. Vascular inflammation and subsequent ischemia were alleviated in vivo by NETosis or IL-1β inhibition in ischemic mice. IL-1β-NETs induce endothelial activation and inflammation in limb ischemia by stimulating STAT1 signaling. Targeting NETs may thus represent a novel therapeutic strategy for inflammatory vascular diseases associated with limb ischemia. Graphical abstract of NETs regulation of the development of vascular inflammation in lower limb ischemia via pSTAT1/STAT1 signaling pathway.

Complicated retroperitoneal diverticulitis presenting with abscess and acute limb ischemia

This case highlights a rare presentation of diverticulitis of the sigmoid colon with perforation into the retroperitoneum complicated by abscess, vertebral osteomyelitis and acute lower extremity ischemia. A late 40-year-old man presented to an emergency department with acute ischemia of his left lower extremity. He was tachycardic with a leucocytosis, an unremarkable abdominal exam and a pulseless, insensate and paralysed left lower extremity. Imaging revealed sigmoid thickening, an abscess adjacent to iliac vasculature and occlusion of the left popliteal artery. The abscess came in contact with prior spine anterior lumbar interbody fusion (ALIF) hardware at L5-S1 vertebrae. The patient was taken urgently to the operating room for embolectomy, thrombectomy and fasciotomy. He was started on antibiotics and later underwent operative drainage with debridement for osteomyelitis. Non-operative management of the complicated diverticulitis failed, necessitating open sigmoidectomy with colostomy. 1 year later, he was symptom-free and the colostomy was reversed.