Comparative effectiveness study of self-directed walking exercise, lower extremity revascularization, and functional decline in peripheral artery disease

OBJECTIVE

Among individuals with peripheral artery disease (PAD), we compared annual change in 6-minute walk performance between participants who neither underwent lower extremity revascularization nor walked for exercise (group 1, reference), those who walked regularly for exercise (group 2), and those who underwent lower extremity revascularization (group 3).

METHODS

Participants were recruited from Chicago-area vascular laboratories and followed annually. Change in 6-minute walk was calculated beginning at the study visit preceding lower extremity revascularization or exercise behavior and continuing for 1 additional year after the therapy was reported. Results are adjusted for age, sex, race, comorbidities, and other confounders.

RESULTS

Of 348 PAD participants, 43 underwent revascularization during median follow-up of 84 months. Adjusted annual declines in 6-minute walk were -96.6 feet/year for group 1, -49.9 feet/year for group 2, and -32.6 feet/year for group 3 (P < .001). Forty-one percent of revascularizations were not associated with ankle-brachial index (ABI) improvement. When group 3 was limited to participants with ABI improvement ≥0.15 after revascularization, annual adjusted changes in 6-minute walk were -97.7 feet/year for group 1, -46.5 feet/year for group 2, and +68.1 feet/year for group 3 (P < .001). When group 3 was limited to participants without ABI improvement ≥0.15 after revascularization, annual adjusted changes in 6-minute walk were -99.2 feet/year for group 1, -48.0 feet/year for group 2, and -61.7 feet/year for group 3 (P < .001).

CONCLUSIONS

A large proportion of PAD participants did not have ABI improvement of at least 0.15 at follow-up study visit after revascularization. The benefits of lower extremity revascularization in patients with PAD appear closely tied to improvements in the ABI after revascularization.

Subintimal angioplasty for chronic lower limb arterial occlusion

BACKGROUND

Subintimal angioplasty (SIA) has become an established percutaneous procedure for the treatment of symptomatic lower limb arterial occlusions in recent years. However, the clinical benefits of this practice remain unclear. The aim of the review was to determine the effectiveness of SIA on clinical outcomes.

OBJECTIVES

To assess the effectiveness of SIA versus any other treatment for patients with chronic lower limb artery occlusion. This will be determined by the effects on clinical improvement, technical success rate, patency rate, limb salvage rate, and morbidity rates.

SEARCH METHODS

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched January 2013) and CENTRAL (2012, Issue 12). Clinical trials databases were also searched.

SELECTION CRITERIA

We planned to include data from randomized controlled trials comparing the effectiveness of SIA and any other management method in the treatment of chronic lower limb arterial occlusion.

DATA COLLECTION AND ANALYSIS

Two authors evaluated the trials identified from the searches for appropriateness of inclusion.

MAIN RESULTS

There were no randomized controlled trials in which SIA was compared with any other treatment.

AUTHORS' CONCLUSIONS

Randomized controlled trial evidence for the effectiveness of SIA is lacking. There is a need for high-quality randomized controlled trials comparing SIA with any other treatment.

Intraoperative lymph mapping with preoperative vein mapping to prevent postoperative lymphorrhea following paramalleolar bypass surgery in patients with critical limb ischemia

PURPOSE

Paramalleolar bypass surgery requires a long incision to harvest the great saphenous vein (GSV), which is often associated with intractable postoperative lymphorrhea. To prevent this complication, we developed a novel method of intraoperative lymph imaging and preoperative vein mapping for vein harvesting.

METHODS

Thirteen consecutive patients with critical limb ischemia (CLI) underwent both preoperative vein mapping and intraoperative lymph mapping (Group A). Duplex vein mapping was performed to mark the GSV. Lymph mapping was performed with indocyanine green fluorescence lymphography. Paramalleolar bypasses were performed using reversed GSV grafts, with careful ligation of the subcutaneous lymph collector vessels above the GSV. The development of intractable postoperative lymphorrhea and the length of the postoperative hospital stay were compared with those in the previous ten consecutive CLI patients without lymph mapping who underwent paramalleolar bypass (Group B).

RESULTS

The occurrence of intractable wound lymphorrhea by the 30th postoperative day was 3/10 (30 %) in Group B, while it was 0/13 (0 %) in Group A (p < 0.05). The length of the postoperative hospital stay was 31.7 ± 8.8 and 57.5 ± 39.5 days (Group A and Group B, respectively, p < 0.05).

CONCLUSIONS

Intraoperative lymph mapping and preoperative vein mapping are technically feasible and can positively contribute to the prevention of postoperative lymphorrhea after GSV harvesting.

Infradiaphragmatic malperfusion of acute aortic dissection associated with previous abdominal aortic aneurysm repair

PURPOSE

To evaluate the association of previous abdominal aortic aneurysm (AAA) graft replacement with infradiaphragmatic malperfusion in patients with acute aortic dissection.

METHODS

Between November 2006 and June 2011, 133 patients were referred to our hospital for management of acute aortic dissection. Eight (6.0 %) of these patients had undergone AAA graft replacement prior to the acute aortic dissection. We compared the computed tomography (CT) images of these 8 patients with those of the remaining 125 patients without previous AAA graft replacement, in terms of organ ischemia as a complication induced by acute aortic dissection.

RESULTS

Infradiaphragmatic malperfusion from acute aortic dissection was confirmed in four of the eight patients who had undergone AAA graft replacement. Contrasted CT scan images indicated that the main cause of infradiaphragmatic malperfusion was collapse of the true lumen from compression by the false lumen into the suprarenal aorta. Although there was no significant difference between the groups in terms of cerebral ischemia and myocardial ischemia, bilateral leg ischemia and visceral ischemia occurred more frequently in the patients who had undergone AAA graft replacement.

CONCLUSION

Previous AAA graft replacement is a risk factor for infradiaphragmatic malperfusion in patients with acute aortic dissection.

[Critical limb ischemia during perioperative period of open surgery for rupture abdominal aortic aneurysm: treatment and prognosis]

OBJECTIVE

To explore the treatment and prognosis of critical limb ischemia during perioperative period of open surgery for ruptured abdominal aortic aneurysm (AAA).

METHODS

Retrospective reviews were conducted for the clinical data of unstable ruptured AAA patients with open repair at our hospital from June 2002 to June 2012 to examine the characteristics and treatment regimens for associated critical limb ischemia.

RESULTS

A total of 46 unstable AAAs were enrolled. There were 37 males and 9 females with an average age of 69 years. All AAAs were repaired by a bifurcated polytetrafluoroethylene graft via a transperitoneal midline incision. Critical limb ischemia was found in 8 patients during or after the procedure. Treatments included additional graft-distal iliac artery bypass (n = 2), anastomotic stoma stenting (n = 2), Fogarty catheter embolectomy plus local thrombolysis (n = 2), Fogarty catheter embolectomy (n = 1) and venous thrombolysis (n = 1). Lower limb necrosis developed in 5 patients (4 unilateral, 1 bilateral) and all of them died.

CONCLUSION

Open repair of ruptured AAA may be associated with a considerate morbidity of critical limb ischemia. Early reconstruction of blood flow improves the prognosis.

[Analysis of cause and treatment of acute limb ischemia complicated in peripheral endovascular interventions]

OBJECTIVE

To discuss the cause and treatment of acute limb ischemia in endovascular therapy of the lower extremity arterial occlusive disease.

METHODS

Clinical data of 54 cases of acute limb ischemia in the endovascular treatment of 685 cases of lower extremity arterial occlusive disease from June 2003 to April 2012 was analyzed retrospectively. There were 43 male and 11 female patients, with a mean age of 72.3 years (ranging from 56 to 82 years). The major causes which resulted in acute limb ischemia included: arterial embolization of 43 cases, arterial thrombosis of 8 cases, arterial dissection of 3 cases. The acute limb ischemia occurred in the process of balloon angioplasty/stent in 36 cases, catheter-directed thrombolysis in 17 cases, Silverhawk atherectomy in 1 cases. Thirty-two cases were treated by endovascular treatment, 9 cases by surgical procedures (bypass or embolectomy), 13 cases by the combination of endovascular therapy and surgical procedures.

RESULTS

Treatment were successfully accomplished in 50 of 54 cases, and failed in 4 cases which had surgical amputation. There were no deaths in all the patients. Forty-five of 54 cases were followed up for the average of 40.3 months. Six cases had ischemic symptoms recurrence in 43 artery embolization patients, in whom 4 cases were cured by endovascular treatment, 2 cases were cured by toe amputation. One case of bypass anastomotic stenosis and one case of stent restenosis were successfully cured by endovascular treatment in 8 arterial thrombosis patients. One cases of below-knee artery stent occlusion in 3 arterial dissection patients was cured by medical treatment. Four cases of amputation patients were followed up in good condition.

CONCLUSIONS

Most patients of acute limb ischemia complicated in endovascular therapy could be treated by endovascular therapy. Surgical procedures in time is still the best choice for the patients in whom the endovascular therapy was not satisfied.

Misdiagnosis of soft tissue sarcomas of the lower limb associated with deep venous thrombosis: report of two cases and review of the literature

BACKGROUND

Deep venous thrombosis (DVT) or pulmonary embolism (PE) is a rare, but not exceptional presentation of soft tissue sarcomas (STSs). Due to the remarkable difference in the incidence between DVT or PE and STSs, this type of STS presentation is usually associated with a considerable delay in tumor diagnosis and treatment.

CASE PRESENTATION

We describe two cases of STS who presented with DVT and PE. Physical and radiographic examination only showed the presence of DVT. Both patients were treated for DVT or PE for several months. Due to the persistence of symptoms and the inefficacy of anticoagulant therapy, magnetic resonance imaging (MRI) was performed, which revealed the presence of a lower limb mass in both cases. The definite diagnosis was reached via excisional biopsy and histological examination.In one case, MRI showed a large tumor in the anterior muscle compartment of the right thigh, with thrombosis of the right common femoral vein and involvement of the ipsilateral common iliac vein and inferior vena cava until the confluence of the renal veins. In the other case, MRI showed a large tumor in the middle third of the right thigh. The lesion was in close proximity to the superficial femoral vein that appeared compressed and showed signs of thrombosis. In both cases, histological examination revealed a high-grade leiomyosarcoma.

CONCLUSION

STSs of the lower extremities can rarely present with DVT or PE. This possibility should be considered in the differential diagnosis of painful leg swelling, especially in patients with recurrent or refractory venous thrombosis. When a STS is suspected, MRI should be obtained followed by excisional biopsy of the eventual mass. A delay in diagnosis and treatment of STSs often results in very poor prognosis.Level of evidence. IV.

[Contrast of curative effect and complications between peripheral venous thrombolysis and catheter-direct thrombolysis for acute deep venous thrombosis in lower limbs]

OBJECTIVE

To evaluate the effects of catheter-direct thrombolysis in acute deep venous thrombosis (DVT).

METHODS

A total of 86 cases were divided into 2 groups of peripheral venous thrombolysis (group A, n = 33) and catheter-direct thrombolysis (group B, n = 53). The curative effect of two groups was compared by swelling rate and vascular potency.

RESULTS

No significant difference existed in swelling rate between two groups (P > 0.05). Vascular patency rates of group B was significantly better than those of group A (P < 0.01). The incidence of bleeding had no significant difference (P > 0.05) and there was no asymptomatic pulmonary embolism in two groups.

CONCLUSION

Both treatments of acute DVT are effective in improving symptoms. But catheter-directed thrombolysis results in significant vascular patency rate and does not increase the risk of thrombolytic bleeding.

Platelet antiaggregation therapy and subinguinal endovascular revascularization

BACKGROUND

Platelet antiaggregation therapy (PAT) is widely acknowledged to be a positive prognostic factor after revascularization, either at the coronary or the peripheral level. This study evaluated the results of infrainguinal endovascular procedures performed for critical ischemia, in accordance with patient compliance to clopidogrel treatment.

MATERIALS AND METHODS

This retrospective study included patients who underwent infrainguinal endovascular therapy for critical ischemia between January 2003 and December 2009. For 1 month, patients received the same postoperative PAT protocol: aspirin associated with clopidogrel, and then clopidogrel in the long term. Patient follow-up was set at 3 months, 6 months, 1 year, and then yearly thereafter. Survival rates, primary patency (PP), and limb salvage (LS) were studied in accordance with therapy compliance. Patients were classified into 2 groups: group 1 for compliant patients and group 2 for noncompliant patients in the long term. From January 2003 to December 2009, 153 infrainguinal endovascular procedures were performed on 150 patients experiencing critical ischemia who had benefited from the authors' postoperative PAT protocol.

RESULTS

Both groups were comparable in terms of comorbidity. Of the procedures performed in groups 1 (N = 105) and 2 (N = 45), 62.8% (n = 66) and 44.4% (n = 20), respectively, were femoral, 14.3% (n = 15) and 22.2% (n = 10), respectively, were infrapopliteal, and 22.9% (n = 24) and 33.4% (n = 15), respectively, were mixed. Mean follow-up time was 30.3 ± 20.2 months (range, 1-70 months). The survival rate was comparable between the groups (P = 0.46). PP and LS rates were significantly higher in group 1 than in group 2 (PP: 84% vs. 80%, respectively, at 1 year, 79% vs. 50%, respectively, at 2 years, 65% vs. 30%, respectively, at 3 years, and 60% vs. 18%, respectively, at 4 years; P = 0.02; LS: 92% vs. 78%, respectively, at 1 year, 86% vs. 62%, respectively, at 2 years, 80% vs. 55%, respectively, at 3 years, and 77% vs. 36%, respectively, at 4 years; P = 0.04).

CONCLUSIONS

This study shows that in common practice, 31% of patients stop their clopidogrel therapy, with a negative impact on PP and LS. These results indicate that medical follow-up after endovascular surgery must be reinforced.

Alloplastic bypass material below the knee: actual rationale

AIM

The greater saphenous vein is considered as material of first choice for a below-knee bypass. A high number of below knee synthetic, polytetrafluoroethylene or knitted polyester, bypass grafts in the institution of the senior author formed the basis to analyze factors for outcome of below-knee synthetic grafts.

METHODS

A total of 533 patients (327 men, 206 women; age: 71.2 ± 10.3 years), who had their first below knee bypass, were followed-up for up-to 9 (4.1 ± 2.6) years. Survival, primary and secondary patency, and limb salvage were compared between vein bypasses and synthetic grafts by Kaplan Meier analysis. Within the group of 377 patients with synthetic grafts comorbidities, previous interventions, indications, graft diameter, and technical aspects were related to outcome including univariate (log-rank) and multivariate (Cox Proportional Hazard Ratio) statistics.

RESULTS

The greater saphenous vein was superior to synthetic graft in primary and secondary patency as well as limb salvage (5 year limb salvage 73.3% vs. 56.7%, P=0.001). In patients with a synthetic bypass, relevant preoperative factors for higher patency rates were hypertension, coronary heart disease and no previous endovascular intervention. Patency and limb salvage was significantly improved for anastomoses not to a single crural vessel. Adding a St. Mary's Boot as cuff technique did not improve the results. In multivariate analysis, independent factors for higher primary patency were no previous endovascular intervention, low severity of peripheral arterial occlusive disease, coronary heart disease and age above 65. Additionally, femoropopliteal and tibioperoneal anastomoses were related to better limb salvage.

CONCLUSION

The greater saphenous vein reveals the best results for below-knee bypass grafts. However, if a vein is not available, synthetic grafts appear to be an valuable alternative especially in patients with no previous radiologic intervention, coronary heart disease, and age over 65.

The analysis of limbs acute ischemia during seasons on the territory of South Serbia

The aim of this study was to examine the seasons variations in incidence of limbs acute ischemia (LAI) as well as the connection between seasons with location of LAI, old age and gender. During the three year period between January 2009 and December 2011, at the Clinic for Vascular Surgery, Clinical Center of Nis, Serbia, 167 patients were hospitalized diagnosed with limbs acute ischemia. There was no statistically significant difference in patients distribution with LAI compared with seasons (p=0.726) and months of the year (p=0.0741). There was no statistically significant difference in patients age (p=0.066), sex (p=0.923) and LAI localization (p=0.219 ) in different seasons. The absence of seasonal and monthly patterns for the AIE creation as well as its localization is followed by the absence of a connection between the age and the sex..

Risk-adjusted strategies in the prevention of early arterial thrombosis following lower extremity arterial reconstruction: a comparison of unfractionated versus low molecular weight heparin

AIM

In vascular surgery postoperative thrombosis prophylaxis must sufficiently prevent arterial thrombosis. This cohort study examines different therapeutic approaches of unfractionated heparin (UFH) or low molecular weight heparin (LMWH) after vascular reconstruction.

METHODS

Four hundred seventy-five patients entered the study between 2005 and 2008. Our clinical routine made a differentiation between low-risk patients (N.=375) and patients with peripheral bypass, which were grouped as high-risk (N.=148). We changed our postoperative anticoagulation management after 24 months in the low-risk and after each 16 months in the high-risk group. The anticoagulation of low-risk patients consisted of either two applications of 7.500 IU UFH subcutaneously (N.=158) or one daily application of 40 mg LMWH each up to discharge (N.=169). High-risk patients received either 25.000 IU UFH i.v. over 24 hours and 4 days (N.=48), 2-times (N.=51) or one-time weight-adjusted LMWH (N.=49) up to discharge (1 mg/kg body weight). Minor complications (bleedings) were differentiated from major early graft occlusion during the postoperative course. Further follow-up was not done for this study.

RESULTS

Low risk: under LMWH, complications could be significantly reduced (P=0.001). Under LMWH significantly fewer occlusion complications occurred (P=0.01) and operation-induced hemorrhages were less frequently observed (P=0.05), this was significant in the complete low-risk group. High-risk: the one-time weight-adjusted LMWH group similarly exhibited many occlusions, like the unfractionated group (NS). The two-time LMWH treatment was significantly superior to the one-time application with respect to occlusion followed by amputations (P=0.03). Minor complications could be minimized overall by administration of LMWH and its dose reduction (NS).

CONCLUSION

The differentiation between patients with high and low risk seems reasonable. An improvement could be achieved by differentiated LMWH application. Synthetic specific antifactor Xa substances (fondaparinux) or other medications could lead in future to other changes in the management of vascular surgery patients and should be further evaluated.

[Algorithm of modern technologies for outpatient surgical treatment of varicose disease of the lower extremities]

The results of ambulatory surgical treatment for the 2007 - 2012 yrs period of 736 patients, suffering varicose disease of lower extremities (VDLE) with chronic venous insufficiency Class C0-C6, according to CEAP (Clinical Etiological Anatomical Pathophysiological) classification, were analyzed. In 258 patients intraoperative truncal scleroobliteration was used and in 124 -endovenous laser coagulation, in 47 - subfascial endoscopic dissection of perforant veins, in 307 - microsclerotherapy, compressive treatment, medicinal therapy. The treatment algorithm of ambulatory surgery of VDLE was elaborated, basing on the analysis of the results of treatment.

Techniques and outcome of retrograde crural artery revascularization

In complex popliteal to infrapopliteal occlusions, an endovascular recanalization attempt can fail in a substantial number of cases. The additional use of a retrograde approach seems feasible and safe and can favorably modify this failure rate. However, this is a technique that requires training and is associated with a learning curve. Although this technique is widely practiced among experienced endovascular specialists, the literature contains reports of less than 100 of these cases. We present our experience with the retrograde approach for the treatment of complex tibial arterial disease. Insights into the technical aspects of the procedure and optimal case selection are discussed.

Reproducibility of rest and exercise stress contrast-enhanced calf perfusion magnetic resonance imaging in peripheral arterial disease

BACKGROUND

The purpose was to determine the reproducibility and utility of rest, exercise, and perfusion reserve (PR) measures by contrast-enhanced (CE) calf perfusion magnetic resonance imaging (MRI) of the calf in normal subjects (NL) and patients with peripheral arterial disease (PAD).

METHODS

Eleven PAD patients with claudication (ankle-brachial index 0.67 ±0.14) and 16 age-matched NL underwent symptom-limited CE-MRI using a pedal ergometer. Tissue perfusion and arterial input were measured at rest and peak exercise after injection of 0.1 mM/kg of gadolinium-diethylnetriamine pentaacetic acid (Gd-DTPA). Tissue function (TF) and arterial input function (AIF) measurements were made from the slope of time-intensity curves in muscle and artery, respectively, and normalized to proton density signal to correct for coil inhomogeneity. Perfusion index (PI) = TF/AIF. Perfusion reserve (PR) = exercise TF/ rest TF. Intraclass correlation coefficient (ICC) was calculated from 11 NL and 10 PAD with repeated MRI on a different day.

RESULTS

Resting TF was low in NL and PAD (mean ± SD 0.25 ± 0.18 vs 0.35 ± 0.71, p = 0.59) but reproducible (ICC 0.76). Exercise TF was higher in NL than PAD (5.5 ± 3.2 vs. 3.4 ± 1.6, p = 0.04). Perfusion reserve was similar between groups and highly variable (28.6 ± 19.8 vs. 42.6 ± 41.0, p = 0.26). Exercise TF and PI were reproducible measures (ICC 0.63 and 0.60, respectively).

CONCLUSION

Although rest measures are reproducible, they are quite low, do not distinguish NL from PAD, and lead to variability in perfusion reserve measures. Exercise TF and PI are the most reproducible MRI perfusion measures in PAD for use in clinical trials.

[Endovenous laser obliteration and combined phlebectomy for treatment of varicose veins in elderly and senile patients]

In the available literature, we have found no comparative data on the efficiency and safety of endovenous laser ablation (EVLA) and traditional phlebectomy in elderly and senile patients. According to our results, in elderly and senile patients, the pain syndrome is much less pronounced after EVLA as compared with phlebectomy, the frequency of ecchymosis with an area of more than 100 cm2 and distal thrombosis of deep veins is lower. In the analyzed groups, there are no significant differences in the frequency of post-surgical complications after surgical intervention. Both EVLA and phlebectomy eliminate pathological reflux of the great saphenous vein with the same degree of reliability, within the period of examination of 1 year. In elderly and senile patients, the time for return to daily activity is significantly reduced after EVLA as compared to that after combined phlebectomy.

[Seasonal cyclicity of acute arterial ischaemia and acute ascending varicothrombophlebitis]

The authors studied the seasonal cyclicity of the thrombotic and embolic process in the veins of the upper and lower extremities, as well as acute ascending varicothrombophlebitis in the great and small saphenous veins over eleven years. The study included a total of 1,513 patients. Of these, 593 (39.1%) presented with arterial ischaemia and 920 (66.9%) patients had ascending thrombophlebitis. The obtained findings showed the seasonal cyclicity of the thrombotic and embolic processes in the peripheral arteries and superficial veins. The maximal number of arterial thrombi was revealed in winter and that of embolisms and ascending varicothrombophlebitis in the spring period. No seasonal dependence for severe grade arterial ischaemia (category III according to the TASC II classification) was revealed.

[Chemichal desympathization in the treatment of throphic ulcer in patients with varicose veins of the lower limbs]

The in vivo study on 25 rabbits and clinical study, involving 60 patients with lower limbs' varicose disease and trophic ulcers was carried out. The in-vivo study was based on the chemical distruction of the sympathic trunk by injecting 95% ethanol and 6% phenol paraneurally along the vascular bundle in the ear. The regeneration of the sympathic neural trunk was registered within 2-3 months after the injury. In human patients the US-guided chemical desympathization led to the increase of the capillary circulation (1.9 times at rest and 0.3 times under the load) during 2 months. The fact favoured the faster regress of inflammatory process in the ulcer.