Outcomes of infrainguinal bypass determined by age in the Vascular Study Group of New England

BACKGROUND

Many believe extremes of age correlate with poorer outcomes in treatment for lower extremity peripheral arterial disease (PAD). We hypothesized that the youngest patients would have significantly poorer outcomes compared with older cohorts due to the precocious nature of their PAD.

METHODS

We studied all patients in the Vascular Study Group of New England database undergoing infrainguinal bypass for PAD between 2003 and 2013. Age was grouped by <50 years, 50 to 79 years, and ≥80 years. Our primary outcomes were 1-year freedom from a major adverse limb event (MALE), defined as ipsilateral amputation or need for secondary intervention, and amputation-free survival. A second analysis was performed to analyze the subgroup of patients aged <50 years with critical limb ischemia (CLI), which included a Cox regression model to determine risk factors for MALE or death at 1 year.

RESULTS

Of 5265 patients who were treated with infrainguinal bypass for PAD, 324 (6.2%) were aged <50 years. The mean age was 44.6 years, and 66.4% were male. The proportion of African Americans was significantly higher in the youngest age group (<50 years: 6.8% vs 50-79 years: 3.5%, P = .002; vs ≥80 years: 3.5%, P = .013). More bypasses were done for claudication than acute limb ischemia in patients aged <50 years (33.3% vs 11.4%). More vein grafts were used vs prosthetic (<50 years: 72.1% vs 50-79 years: 65.9%, P = .024; vs ≥80 years: 62.6%, P = .002). Fewer concomitant proximal procedures were performed compared with the older groups (<50 years: 37.7% vs 50-79 years: 51.1%, P < .001; vs ≥80 years: 39.5%, P = .045). More young patients returned to the operating room within their initial hospitalization for early graft thrombosis (<50 years: 5.6% vs 50-79 years: 2.9%, P = .001; vs ≥80 years: 2.4%, P = .009) and revision (<50 years: 4.7% vs 50-79 years: 2.2%, P = .012; vs ≥80 years: 1.4%, P = .002) compared with the older patients. Overall, MALE-free survival was similar across age groups (P = .323), as were patency and amputation rates. When considering only patients with CLI, MALE-free survival in the youngest patients was again similar (P = .171) but with significantly more major amputations at 1 year (P = .022).

CONCLUSIONS

For patients aged <50 undergoing infrainguinal bypass surgery, this large series demonstrates similar overall medium-term graft-related outcomes compared with older cohorts. Further, although the youngest patients with CLI have similar MALEs, their amputation rates are higher than in older cohorts.

Percutaneous endovascular thrombosuction for acute lower limb ischemia: a 5-year single center experience

AIM

The aim of this paper was to report a 5-year single center experience with the use of percutaneous endovascular thrombosuction (PET) for acute lower limb ischemia (ALLI).

METHODS

All patients that underwent PET for ALLI within the period January 2009-December 2013 in our institution were included. Data were collected retrospectively.

RESULTS

A total of 262 patients (132 female, mean age 74.5±11 years) were treated. Level of severity of ALLI preoperatively was stratified as class I (viable) in 76% (199/262) of patients, class IIa (threatened marginally) in 19.4% (51/262), and class IIb (threatened immediately) in 4.6% (12/262). Initial technical success was 91% (237/262). Additional PTA was performed in 29.8% (78/262) of patients, and PTA with stenting in 27.5% (72/262). Open surgery due to technical failure of PET was required in 4.2% (11/262) of patients. Thirty-day mortality was 4.6% (12/262). Perioperative complications occurred in 9.2% (24/262). Thirty-day amputation rate was 3.8% (10/262). The mean duration of follow-up was 26.2±16 months. Estimated cumulative survival was 84.2±2.5% at 1 year, and 73.7±3.6% at 3 years. Estimated freedom from amputation during follow-up was 92.4±1.8% at 1 year, and 91.2±2% at 3 years. Estimated freedom from reintervention was 90.4±2% at 1 year, and 80±3.7% at 3 years.

CONCLUSION

PET in selected patients with ALLI provides high initial technical success, low mortality and morbidity rates, and favorable early and mid-term limb salvage rates.

Post-treatment neutrophil-lymphocyte ratio independently predicts amputation in critical limb ischemia without operation

OBJECTIVES

Limited information is available concerning the post-treatment neutrophil-lymphocyte ratio in critical limb ischemia patients who receive conservative therapy. Accordingly, this study was designed to evaluate the predictive value of the post-treatment neutrophil-lymphocyte ratio in critical limb ischemia patients without surgery.

METHOD

From January 2009 to January 2011, critical limb ischemia patients were admitted to a vascular center. The demographic data, patient histories, comorbidities and risk factors were documented, and the differential cell count was determined at admission and seven days later after conservative therapy. The cutoff value of the post-treatment neutrophil-lymphocyte ratio was determined by an ROC curve. Patients were divided into groups A and B according to the cutoff value. Amputation-free survival was compared between groups. Univariate and multivariate analyses were used to identify independent risk factors.

RESULT

A total of 172 patients were identified with a mean age 71.98±10.09 years; among them, 122 were male. A value of 3.8 was identified as the cutoff value of the post-treatment neutrophil-lymphocyte ratio. Groups A (post-treatment neutrophil-lymphocyte ratio ≥3.8) and B (post-treatment neutrophil-lymphocyte ratio <3.8) showed a significant difference in amputation-free survival (P<0.001). The 1-year, 2-year and 3-year amputation-free survival rates were 79.6%, 55.6% and 46.3%, respectively, in group A; however, in group B, these values were 89.7%, 79.3% and 75.9%, respectively. The post-treatment neutrophil-lymphocyte ratio was identified as an independent predictive factor for amputation in critical limb ischemia patients (P<0.001).

CONCLUSION

The post-treatment neutrophil-lymphocyte ratio is an independent predictive factor for amputation in critical limb ischemia patients. Patients with a post-treatment neutrophil-lymphocyte ratio ≥3.8 are likely to suffer from amputation; amputation-free survival usually occurs in patients with a post-treatment neutrophil-lymphocyte ratio <3.8.

Oxidative and inflammatory biomarkers of ischemia and reperfusion injuries

Ischemia-reperfusion injuries occur when the blood supply to an organ or tissue is temporarily cut-off and then restored. Even though the restoration of blood flow is absolutely essential in preventing tissue death, the reperfusion of oxygenated blood to the oxygen-deprived areas may in itself augment the tissue damage in excess of that produced by the ischemia alone. The process of ischemia-reperfusion is multifactorial and there are several mechanisms involved in the pathogenesis. Ample evidence shows that the injury is in part caused by an excessive generation of reactive oxygen species or free radicals. The free radicals consequently initiate an inflammatory response, which in some cases may affect distant organs, thus causing remote organ injuries. Ischemia-reperfusion injuries are a common complication in many diseases (acute myocardial infarctions, stroke) or surgical settings (transplantations, tourniquet-related surgery) and they have potential detrimental and disabling consequences. The tolerance of ischemia-reperfusion has proven to be time-of-day-dependent and the size of myocardial infarctions has proven to be significantly higher when occurring in the dark-to-light period. This period is characterized by and coincides with a rapid decrease in the plasma levels of the hormone melatonin. Melatonin is the body's most potent antioxidant and is capable of both direct free radical scavenging and indirect optimization of other anti-oxidant enzymes. It also possesses anti-inflammatory properties and is known to inhibit the mitochondrial permeability transition pore during reperfusion. This inhibiting property has been shown to be of great importance in reducing ischemia-reperfusion injuries. Furthermore, melatonin is a relatively non-toxic molecule, which has proven to be safe for use in clinical trials. Thus, there is compelling evidence of melatonin's effect in reducing ischemia-reperfusion injuries in many experimental studies, but the number of human clinical trials is very limited. In this PhD thesis we set out to explore the oxidative and inflammatory biochemical markers of ischemia and reperfusion injuries and the possible effect of melatonin on these markers. We have reviewed the literature on the tourniquet-related oxidative damage and found that ischemic preconditioning and the use of propofol could significantly reduce the release of such markers. However, the relevance of this reduction in terms of clinical outcomes is still to be investigated (paper 1). We undertook the characterization of a human ischemia-reperfusion model without the influencing factors of surgery and anesthesia, and subsequently found ways to improve this model (paper 2). In order to apply an intracoronary melatonin administration, we investigated whether melatonin could be dissolved in non-ethanol based buffers and still activate the melatonin receptors (paper 3). We found this to be possible, and in a porcine closed-chest model of acute myocardial infarction (AMI) we randomized the pigs to intracoronary and systemic melatonin or placebo in order to test whether melatonin could attenuate the oxidative and inflammatory biomarkers following reperfusion (paper 4). The outcomes were not optimal for this model, and the effect of melatonin still remains to be explored in a large animal model. We are currently still awaiting the results of the IMPACT-trial - a randomized, placebo-controlled, clinical trial exploring the effect of intracoronary and systemic melatonin given to patients suffering from AMI and undergoing primary percutaneous coronary intervention (pPCI) (paper 5). Though pPCI is undisputedly life-saving, it holds a built-in consequence of aggravating the ischemic injury, paradoxically due to the reperfusion. The optimization of existing treatments and the exploring of new suitable interventions, such as melatonin, for minimizing the ischemia-reperfusion injuries is therefore of great interest.

Update on intra-arterial thrombolysis in patients with lower limb ischemia

Intra-arterial thrombolysis has become the most important minimally-invasive treatment option to treat acute lower limb ischemia. Although hemorrhagic stroke is a dreaded complication, intra-arterial thrombolysis is considered beneficial to many fragile and elderly patients where vascular surgery is not an option. This review outlines current results after intra-arterial thrombolysis with low dose recombinant tissue plasminogen activator (rtPA) from 2001 to 2012 in two large vascular centers in Sweden. There was an increasing number of thrombolysis of occluded endoprosthesis and decreasing thrombolysis of occluded bypasses during this time period. Technical success rate for thrombolysis of occluded endoprostheses, bypasses and native artery occlusion was 91%, 89% and 73%, respectively. Amputation-free survival rate at one year was 73%. Popliteal arterial aneurysm and anemia were independently associated with dismal amputation-free survival at 30 days. Independent factors associated with dismal amputation-free survival at long-term were foot ulcers, motor deficit, renal insufficiency and anemia. Major hemorrhage occurred in 104 procedures (13.9%); 43 (5.7%) were so severe that thrombolysis was discontinued in advance. All three (0.4%) hemorrhagic strokes were fatal. Preoperative severe limb ischemia with motor deficit was the only independent risk factor for major bleeding. Simultaneous heparin infusion was not associated with increased risk of major bleeding or improved leg salvage or survival. In conclusion, intra-arterial thrombolysis with rtPA for lower limb ischemia was effective, with few major bleeding complications. Simultaneous heparin infusion offered no advantage. Thrombolysis in embolism due to popliteal artery aneurysm is the most important step to improve run-off and a prerequisite to succeed with operative treatment.

Current outcomes of emergency large bowel surgery

INTRODUCTION

Emergency large bowel surgery (ELBS) is known to carry an increased risk of morbidity and mortality. Previous studies have reported morbidity and mortality rates up to 14.3%. However, there has not been a recent study to document the outcomes of ELBS following several major changes in surgical training and provision of emergency surgery. The aim of this study was therefore to explore the current outcomes of ELBS.

METHODS

A retrospective review was performed of a prospectively maintained database of the clinical records of all patients who had ELBS between 2006 and 2013. Data pertaining to patient demographics, ASA (American Society of Anesthesiologists) grade, diagnosis, surgical procedure performed, grade of operating surgeon and assistant, length of hospital stay, postoperative complications and in-hospital mortality were analysed.

RESULTS

A total of 202 patients underwent ELBS during the study period. The mean patient age was 62 years and the most common cause was colonic carcinoma (n=67, 33%). There were 32 patients (15.8%) who presented with obstruction and 64 (31.7%) had bowel perforation. The overall in-hospital mortality rate was 14.8% (n=30). A consultant surgeon was involved in 187 cases (92.6%) as either first operator, assistant or available in theatre.

CONCLUSIONS

ELBS continues to carry a high risk despite several major changes in the provision of emergency surgery. Further developments are needed to improve postoperative outcomes in these patients.

Contemporary management of critical lower limb ischemia in TASC D lesions with subintimal angioplasty in femoro-popliteal lesions, tibial angioplasty and sequential compression biomechanical device for infra-inguinal arterial occlusion. Experience and quality of life outcome learned over 25 years

AIM

Patients with end-stage critical limb ischemia (CLI) survive on borrowed time and amputation is inevitable if an aggressive management stratagem is not instigated. Our primary aim was to equate effectiveness of subintimal angioplasty (SIA) and tibial balloon angioplasty (TBA) in sustaining clinical improvement and amputation free survival (AFS) in patients with CLI TASD II D. Moreover, patients with severe CLI, who were not suitable for revascularization and who were offered therapy with a sequential compression biomechanical device (SCBD) were scrutinised as part of a comprehensive lower limb salvage program.

METHODS

From 2002-2012, 5876 patients were referred with peripheral vascular disease (PVD); 987 presented with CLI and 798 had intervention; 189 patients presenting with CLI were not candidates for revascularisation, out of which 171 were offered SCBD. We formed a prospective observational group study of 441 patient who had TASC D disease. All of these patients presented as emergencies and were allocated to the next available treatment list. Duplex ultrasound arterial mapping (DUAM) was the sole preoperative investigation tool in 92% of all cases. Of the 441 patients studied, 190 patients (206 procedures) has SIA for TASC D femero-popliteal occlusions, 80 patients (89 procedures) had TBA and cool eximer laser angioplasty (CELA) for tibial artery occlusions and 171 patients with severe CLI were not suitable for revascularization and joined the SCBD program. Mean age (SIA 73±13 years vs. TBA/CELA 74±8 years vs. SCBD 75±13 years), and comorbidity severity scores (P>0.05) were similar between groups.

RESULTS

Perioperative mortality within the SIA group was 1.6% vs. 0% within the TBA group and 0.6% in SCBD. Length of hospital stay within the TBA group was 3.8±2 days vs. SIA 14±16 days, P<0.0001. The 5-year freedom from major adverse events (MAE) for the SIA group was 68% that was comparable to the results obtained for both the TBA group; 59%, and SCBD group: 62.5% (P=0.1935). Five-year freedom from target lesion revascularization was 85.9% within the SIA group and 79% within the TBA group. A sustained clinical improvement was seen in 82.8% of primary SIA and 68% of TBA, which mimics the outcome of SCBD at 68% at one year. A total of 83% SCBD patients had no rest pain within one week of starting the program and gangrene remained dry and non-progressive. Ulceration healed in all but 12 patients. There were no device-related complications. Limb salvage was 94% at 5 years. All-cause survival was 69%. Quality time spent without symptoms of disease or toxicity of treatment (Q-TWiST) was 24.7 months for SIA and 8.5 months for TBA and was 38.13 for SCBD for a total of 708 months of usage. Cost per quality adjusted-life years (QALY) for SIA was € 5662.79, € 12,935.18 for TBA and € 2943.56 for SCBD.

CONCLUSION

All treatment pathways augmented patient-specific Q-TWiST with substantial cost reduction. SIA, TBA and SCBD expand AFS and symptom-free survival. All treatment modalities are minimally invasive and allow for a high patient turnover without compromising limb salvage, once they are performed by experienced vascular surgeons in high deliberate practice volume centers.

Drug-eluting balloons for femoropopliteal lesions show better performance in de novo stenosis or occlusion than in restenosis

OBJECTIVE

Although drug-eluting balloons (DEBs) have shown promising results treating de novo (DN) atherosclerotic lesions and appear to have been widely adopted in Europe, their long-term efficacy in the broad spectrum of femoropopliteal restenosis (RE) remains to be proven. The purpose of the study was to assess the efficacy of paclitaxel-DEBs in restenotic (stented and nonstented) vs DN stenotic femoropopliteal arteries.

METHODS

The study prospectively enrolled 100 patients undergoing femoropopliteal endovascular intervention by DEB for RE or DN stenosis. Patients who received additive atherectomy were excluded. The primary end point was the primary patency (PP) rate at 12 months. Secondary end points were sustained clinical improvement and clinically driven target lesion revascularization.

RESULTS

DEBs were used to treat 105 limbs for intermittent claudication (82 [78%]) or critical limb ischemia (23 [22%]) in 100 patients. Of these, 111 lesions were DN stenosis (46 [41%]) or RE (65 [59%]). The overall PP was 86% at 6 months and 74% at 12 months. PP of DN stenosis was higher at 6 months (93% vs 81%) and was significantly (P = .021) better than RE at 12 months (85% vs 68%). Sustained clinical improvement based on Rutherford classification was significant in both groups (P < .001). Target lesion revascularization was significantly lower in DN stenosis compared with RE at 12 months (15% vs 32%; P = .021).

CONCLUSIONS

DEB angioplasty is an effective therapy for DN femoropopliteal lesions. The results of DEB angioplasty for RE are inferior compared with DN stenosis after 12 months. Nevertheless, results of DEB angioplasty for RE seem comparable with technically more demanding literature-derived strategies.

Hybrid revascularization of complex multilevel disease: a paradigm shift in critical limb ischemia treatment

Critical limb ischemia frequently occurs on a background of extensive co-morbidities and carries a poor prognosis which requires urgent management. Disease severity and patient comorbidity influence the initial choice of management which according to traditional paradigms, is a choice between open or endovascular repair. Over the last decade hybrid intervention, which is the planned combined use of both open and endovascular techniques, has increasingly been used to tackle multilevel disease. In this review we look at the techniques and results of hybrid surgery. This technique is ideal for multilevel lesions, as it is minimally invasive, allows prompt limb revascularization as opposed to the delays inherent in staged procedures and it appears to be more convenient to patients. It also leads to reduced length of hospital stay and reduces overall cost. Most importantly it offers an alternative to open revascularization in medically high risk patients. The success and popularity of hybrid interventions has been underpinned by advances in stent and balloon technology and the advent of the hybrid operating theatre which has allowed multiple techniques to be used simultaneously. Iliac angioplasty and stenting is now the first line of treatment for TASC C/D iliac lesions with good technical success and long-term patency. In patients who also have common femoral disease, endarterectomy can be combined with iliac stenting and this has now almost replaced open bypass. Most series for a variety of hybrid procedures report good limb salvage rates, with morbidity and mortality data considered equal to or better than open bypass procedures. Careful patient selection and detailed preoperative planning are essential to achieve these excellent results. Studies have reported on prospective series or retrospective analysis for various hybrid techniques, including non randomized trials comparing hybrid and open surgical treatment. Ideally, a randomized controlled trial comparing open and hybrid treatment is needed to minimize confounding variables.

Long-term results of PTFE trilaminate graft versus venous graft and composite graft for below-the-knee revascularization

AIM

We report our experience with the use of PTFE trilaminate graft Advanta SST (Atrium Maquet™) versus autologous great saphenous vein (AGSV) and composite PTFE trilaminate-vein graft for below-the-knee (BTK) revascularization.

METHODS

Data of all consecutive patients who underwent either a BTK or a distal femoro-popliteal bypass from January 2004 to March 2013 using Advanta SST, AGSV or composite Advanta SST-vein graft were retrospectively reviewed and outcomes were analyzed. Kaplan-Meier method with Log-rank test was used to estimate survival, limb salvage and patency rates. Chi-square test was used to evaluate risk factors affecting outcomes. P value <0.05 was considered significant.

RESULTS

Sixty-one patients (48 males, 78.7%; median age 73 years, IQR 66-80) underwent a BTK/distal revascularization for peripheral artery disease causing critical limb ischemia (52 patients, 85.2%) or disabling claudication (9 patients). Advanta SST graft was used in 17 patients (group A), AGSV in 30 (Group B) and composite Advanta-AGSV graft in the remaining 14 (group C). Patients' demographics and risk factors were similar among the three groups, being hypertension and smoke the most frequent comorbidities. When Advanta SST was employed, the median duration of intervention was significantly lower than using vein or composite grafts (212 minutes, IQR 177-257; 270 minutes, IQR 220-375, P=.02; 327.5 minutes, IQR 252.5-405, P=0.003 respectively). At 30-days, wound complications tended to be significantly higher in Group B (13.3%) and C (11.7%) than in group A (0%), P=0.02. At long term, survival, primary assisted and secondary patency rates did not differ significantly among the three groups. Limb salvage was similar as well among group A, B and C (P=0.29), being 81.2+9.7%, 89.4+5.8% and 67.7+13.5% respectively at 1 year and 81.2+9.7%, 83.4%+7.9% and 54.2%+16.2% respectively at 3 years. Primary patency rate at 1 year was significantly better for group B than for group A and C (71.2+8.6%, 49.6+12.7% and 47.6+14.1% respectively, P=0.02), but after 1 year the patency rate for group B and A was similar (55.5+10.6% and 49.6+12.7% respectively), being for group C significantly worse (19+11.8%). A history of previous or current smoke affected significantly primary patency rate in group A (RR 0.39, 95%CI 0.08-0.95, P=0.03).

CONCLUSION

Long-term results of the use of Advanta SST graft for BTK/distal revascularization seems to be promising, with significant lower duration of the operation and wound complications. At long term, survival, limb salvage, primary assisted and secondary patency rates did not differ significantly among the three groups. The AGSV still remains the best graft in terms of primary patency at 1 year, but after one year primary patency rates using the Advanta SST compare favorably to those of AGSV, while composite bypass grafts have the worst performance. These results need to be increased further.

Antiplatelet therapy in critical limb ischemia: update on clopidogrel and cilostazol

Antiplatelet therapy is essential for critical limb ischemia (CLI) patients, both as primary prevention for ischemic events and as adjuvant pharmacotherapy in order to avoid acute or late thrombo-occlusive events and maintain patency following peripheral endovascular or open surgical limb-salvage revascularization procedures. According to currently updated international guidelines clopidogrel as monotherapy or as part of dual antiplatelet therapy is recommended in CLI patients, while recent evidence delineated the beneficial effect of cilostazol in patients undergoing peripheral endovascular angioplasty or stenting as its administration resulted in a decrease of restenosis and clinically-driven reinterventions, as well as in the enhancement of platelet inhibition. This review aims in discussing recent evidence on the topic of antiplatelet therapy in CLI patients, with a special focus on the use of clopidogrel and cilostazol.

A novel mouse model of ischemic carotid artery disease

Background

Carotid artery occlusive disease gradually develops over time, eventually leading to cerebral infarction and high mortality rate. Animal models replicating cerebral infarction resulting from carotid artery occlusive disease have thus been developed to test potential novel treatments, which could be subsequently administered clinically.

Methods

Adult C57BL/6J male mice were subjected to ameroid constrictor (AC) placement to gradually narrow the bilateral common carotid arteries. Cerebral blood flow (CBF) was measured at several time points. At 7 and 28 days post-operation, post-mortem brain samples were analyzed for ischemic changes.

Results

The mortality rate was 58.8% at 28 days post-operation. Surviving mice with AC showed continuous reduction of CBF by up to 70% of the baseline level at 28 days. Most of the mice (75%) showed multiple cerebral infarctions in the gray and white matter. Non-surviving mice showed critical CBF reduction below 20–30% of the baseline level before death.

Conclusion

The application of the AC on the bilateral common carotid arteries in mice could offer a reliable model of severe cerebrovascular insufficiency due to carotid artery occlusive disease and may thus be useful in exploring pharmacological intervention in stroke through monitoring survival rate, infarct formation, and CBF profile.

Retrograde open mesenteric stenting for acute mesenteric ischemia

OBJECTIVE

Acute mesenteric ischemia (AMI) encompasses the sequels of end-stage untreated chronic mesenteric ischemia and acute mesenteric artery thrombosis. Percutaneous mesenteric artery stenting (PMAS) is the preferred treatment of patients with AMI but is not always feasible. Retrograde open mesenteric stenting (ROMS) is a hybrid technique that combines the advantages of open surgical and endovascular approaches. The literature on the results of this new technique is scarce. The aim of this study was to evaluate the results of ROMS in a consecutive series of patients with AMI.

METHODS

All patients with emergent mesenteric revascularization for AMI between January 2007 and September 2011 were entered in our prospective registry. Technical success, mortality, patency, clinical success, and complication rate at 30 days and 6 and 12 months were assessed.

RESULTS

Sixty-eight patients presented with AMI and 54 underwent PMAS, of which four were unsuccessful and followed by ROMS. Eleven patients were directly treated with ROMS, making a total of 15 patients (10 women and five men; median age, 66 years [interquartile range, 54-73 years]). In all patients, only the superior mesenteric artery was revascularized. In nine of the 15 patients, all three mesenteric arteries were severely stenotic or occluded. Technical success was achieved in 14 patients. At ROMS in two patients, the small bowel was severely ischemic. One of these patients needed a partial bowel resection because of irreversible transmural ischemia. At 30 days, the mortality rate was 20% and the primary patency was 92%. Ten patients underwent unplanned relaparotomy, of whom one needed resection of a large part of the small bowel. At 12 months, the mortality rate was still 20%. The primary patency was 83%. Primary assisted patency was 91%, and secondary patency was 100%. Clinical success at 30 days, 6 months, and 12 months, respectively, was 73%, 67%, and 67%.

CONCLUSIONS

AMI is still a devastating event. If PMAS is not feasible, ROMS is a reliable alternative and is associated with a relatively low mortality and morbidity rate.

Acute mesenteric ischemia after heart surgery

INTRODUCTION

Acute mesenteric ischemia (AMI) is a rare but very severe complication of heart surgery, due especially to the delay in setting the correct diagnosis and choosing the appropriate treatment. There are 4 types, but the most frequent is nonocclusive mesenteric ischemia (NOMI). The main mechanism is represented by great decrease or maldistribution of the splenic blood flow, with negative impact on the integrity of the intestinal mucosa, bacterial translocation and multiorganic failure.

MATERIAL AND METHOD

We present a retrospective study conducted on patients who underwent open heart surgery with cardiopulmonary bypass with non-pulsatile flow. 4 cases of angiographically confirmed NOMI (non-occlusive mesenteric ischemia) were identified. When, based on clinical examination and laboratory findings, acute mesenteric ischemia was suspicioned, superior mesenteric artery angiography was performed via the femoral artery.

RESULTS

The main risk factors were represented by: age over 70 years old, left ventricle ejection fraction (LVEF) 35%,aortic clamping time 100 min., chronic kidney failure,counter-pulsation balloon implant, inotropic medication use,like levosimendan, use of blood components 1 unit of erythrocyte mass. Clinical signs were nonspecific. All patients presented hypoventilation, arterial hypotension, oliguria and,from a biological standpoint, metabolic acidosis and leucocytosis. Superior mesenteric artery angiography was the investigation method of choice. Treatment approach was initially medical, followed by resection of the intestine.Mortality was 100%.

CONCLUSIONS

Acute mesenteric ischemia is a rare but very severe complication in cardiac surgery. It is primordial that the main risk factors be known, and in case of diagnosis suspicion, that it be set as early as possible, along with immediate initiation of an appropriate course of treatment.

Trends in the incidence, treatment, and outcomes of acute lower extremity ischemia in the United States Medicare population

OBJECTIVE

Acute lower extremity ischemia (ALI) is a common vascular surgery emergency associated with high rates of morbidity and mortality. The purpose of this study was to assess contemporary trends in the incidence of ALI, the methods of treatment, and the associated mortality and amputation rates in the U.S. Medicare population.

METHODS

This was an observational study using Medicare claims data between 1998 and 2009. Outcomes examined included trends in the incidence of ALI; trends in interventions for ALI; and trends in amputation, mortality, and amputation-free survival rates.

RESULTS

Between 1998 and 2009, the incidence of hospitalization for ALI decreased from 45.7 per 100,000 to 26.0 per 100,000 (P for trend < .001). The percentage of patients undergoing surgical intervention decreased from 57.1% to 51.6% (P for trend < .001), whereas the percentage of patients undergoing endovascular interventions increased from 15.0% to 33.1% (P for trend < .001). In-hospital mortality rates decreased from 12.0% to 9.0% (P for trend < .001), whereas 1-year mortality rates remained stable at 41.0% and 42.5% (P for trend not significant). In-hospital amputation rates remained stable at 8.1% and 6.4% (P for trend not significant), whereas 1-year amputation rates decreased from 14.8% to 11.0% (P for trend < .001). In-hospital amputation-free survival after hospitalization for ALI increased from 81.2% to 85.4% (P for trend < .001); however, 1-year amputation-free survival remained unchanged.

CONCLUSIONS

Between 1998 and 2009, the incidence of ALI among the U.S. Medicare population declined significantly, and the percentage of patients treated with endovascular techniques markedly increased. During this time, 1-year amputation rates declined. Furthermore, although in-hospital mortality rates declined after presentation with ALI, 1-year mortality rates remained unchanged.

Acute ischemia and bypass occlusion: current options

AIM

Acute limb ischemia (ALI) and bypass occlusion are vascular emergencies and require immediate decisions and therapy. There are a lot of options, and the vascular therapist should be able to provide multiple alternatives. In this article we give on overview over the actual therapeutic options and present the data of a retrospective analysis of bypass occlusions.

METHODS

Therapeutic options of ALI are discussed according to the current literature. For the retrospective study, patients with acute or subacute occlusion of below knee alloplastic bypass were included. Endpoints of the study were secondary patency and limb salvage rate. A prognostic index was calculated to estimate the specific risk.

RESULTS

We analyzed 262 bypass occlusions; 161 patients were male. The majority of patients (N.=249) presented with threatened limb at readmission. After one year, 2/3 of the bypasses showed a reocclusion. Introducing the therapy with bypass thrombolysis enhanced the prognosis significantly. Of the factors examined, cardiac and renal insufficiency had a significant poor influence, whereas therapy with Coumadin enhanced the prognosis in terms of patency. The prognostic index was calculated using the factors identified as relevant in the multivariate analysis.

DISCUSSION

Despite all new technical tools, ALI and bypass occlusion is still associated with a significant risk for limb loss and mortality. Endovascular procedures are excellent options. The prognostic index may be a helpful tool in estimating the patency or risk of limb loss.

Association between statin medications and mortality, major adverse cardiovascular event, and amputation-free survival in patients with critical limb ischemia

OBJECTIVES

The aim of this study was to determine the associations between statin use and major adverse cardiovascular and cerebrovascular events (MACCE) and amputation-free survival in critical limb ischemia (CLI) patients.

BACKGROUND

CLI is an advanced form of peripheral arterial disease associated with nonhealing arterial ulcers and high rates of MACCE and major amputation. Although statin medications are recommended for secondary prevention in peripheral arterial disease, their effectiveness in CLI is uncertain.

METHODS

We reviewed 380 CLI patients who underwent diagnostic angiography or therapeutic endovascular intervention from 2006 through 2012. Propensity scores and inverse probability of treatment weighting were used to adjust for baseline differences between patients taking and not taking statins.

RESULTS

Statins were prescribed for 246 (65%) patients. The mean serum low-density lipoprotein (LDL) level was lower in patients prescribed statins (75 ± 28 mg/dl vs. 96 ± 40 mg/dl, p < 0.001). Patients prescribed statins had more baseline comorbidities including diabetes, coronary artery disease, and hypertension, as well as more extensive lower extremity disease (all p values <0.05). After propensity weighting, statin therapy was associated with lower 1-year rates of MACCE (stroke, myocardial infarction, or death; hazard ratio [HR]: 0.53; 95% confidence interval [CI]: 0.28 to 0.99), mortality (HR: 0.49, 95% CI: 0.24 to 0.97), and major amputation or death (HR: 0.53, 95% CI: 0.35 to 0.98). Statin use was also associated with improved lesion patency among patients undergoing infrapopliteal angioplasty. Patients with LDL levels >130 mg/dl had increased HRs of MACCE and mortality compared with patients with lower levels of LDL.

CONCLUSIONS

Statins are associated with lower rates of mortality and MACCE and increased amputation-free survival in CLI patients.

[Estimation of efficacy of the elaborated algorithm of differential diagnosis and treatment of acute mesenterial ischemia]

Clinical efficacy of the elaborated algorithm for differential diagnosis and treatment was studied, basing on analysis of the main diagnostic clinical features for presence of an acute mesenterial schemia (AMI), the concomitant diseases identification as the risk factors for the AMI occurrence, the results estimation of accessible noninvasive and invasive methods of diagnosis, correlation between the patient's survival indices and conservative and operative treatment, depending on the AMI stage and the patient state.

The FReedom from Ischemic Events-New Dimensions for Survival (FRIENDS) registry: design of a prospective cohort study of patients with advanced peripheral artery disease

BACKGROUND

Advanced lower extremity peripheral artery disease (PAD), whether presenting as acute limb ischemia (ALI) or chronic critical limb ischemia (CLI), is associated with high rates of cardiovascular ischemic events, amputation, and death. Past research has focused on strategies of revascularization, but few data are available that prospectively evaluate the impact of key process of care factors (spanning pre-admission, acute hospitalization, and post-discharge) that might contribute to improving short and long-term health outcomes.

METHODS/DESIGN

The FRIENDS registry is designed to prospectively evaluate a range of patient and health system care delivery factors that might serve as future targets for efforts to improve limb and systemic outcomes for patients with ALI or CLI. This hypothesis-driven registry was designed to evaluate the contributions of: (i) pre-hospital limb ischemia symptom duration, (ii) use of leg revascularization strategies, and (iii) use of risk-reduction pharmacotherapies, as pre-specified factors that may affect amputation-free survival. Sequential patients would be included at an index "vascular specialist-defined" ALI or CLI episode, and patients excluded only for non-vascular etiologies of limb threat. Data including baseline demographics, functional status, co-morbidities, pre-hospital time segments, and use of medical therapies; hospital-based use of revascularization strategies, time segments, and pharmacotherapies; and rates of systemic ischemic events (e.g., myocardial infarction, stroke, hospitalization, and death) and limb ischemic events (e.g., hospitalization for revascularization or amputation) will be recorded during a minimum of one year follow-up.

DISCUSSION

The FRIENDS registry is designed to evaluate the potential impact of key factors that may contribute to adverse outcomes for patients with ALI or CLI. Definition of new "health system-based" therapeutic targets could then become the focus of future interventional clinical trials for individuals with advanced PAD.

Older adults with heel ulcers in the acute care setting: frequency of noninvasive vascular assessment, surgical intervention, and 1-year mortality

OBJECTIVES

To examine how often hospitalized older adults with a diagnosis of heel ulcers are evaluated with noninvasive vascular tests and to determine the impact of invasive vascular or surgical procedures on 1-year mortality.

DESIGN

Retrospective review using an electronic database and chart review of all patients discharged with a diagnosis of heel ulcer between 2006 and 2009.

SETTING

Urban teaching hospital.

PARTICIPANTS

A total of 506 participants aged 65 years and older.

MEASUREMENTS

Data collected included resident characteristics (demographics, medical history, and severity of illness using the Charlson comorbidity index), staging of heel ulcers, rates of noninvasive vascular assessments, vascular and surgical procedures, length of stay, and 1-year mortality.

RESULTS

Thirty-one percent (155/506) of patients with a heel ulcer underwent noninvasive vascular testing and of these 83% (129/155) were found to have underlying ischemia. Twenty-six percent (130/506) of patients underwent at least 1 vascular or surgical procedure. The 1-year mortality rate for patients with stage 1 or 2 disease was 55%; this rose to 70% for patients with stage 3 or 4 ulcers (P = .01), and could not be explained by differences in the Charlson comorbidity index. Patients who underwent a vascular or surgical procedure had a significantly lower mortality compared with those who did not (59% vs 68% P = .04).

CONCLUSION

Older adults with a heel ulcer in the acute care setting are frequently not assessed for underlying ischemia of the lower extremities. The diagnosis carries high 1-year mortality rates. Evidence-based protocols need to be developed to determine which older adults should have a vascular assessment and then undergo an invasive procedure.

Comparison of open and endovascular treatment of acute mesenteric ischemia

INTRODUCTION

Acute mesenteric ischemia (AMI) is a commonly fatal result of inadequate bowel perfusion that requires immediate evaluation by both vascular and general surgeons. Treatment often involves vascular repair as well as bowel resection and the possible need for parenteral nutrition. Little data exist regarding the rates of bowel resection following endovascular vs open repair of AMI.

METHODS

Using the National Inpatient Sample database, admissions from 2005 through 2009 were identified according to International Classification of Diseases, Ninth Revision codes correlating to both AMI (557.0) and subsequent vascular intervention (39.26, 38.16, 38.06, 39.9, 99.10). Patients with a diagnosis of AMI but no intervention or nonemergent admission status were excluded. Patient level data regarding age, gender, and comorbidities were also examined. Outcome measures included mortality, length of stay, the need for bowel resection (45.6, 45.71-9, 45.8), or infusion of total parenteral nutrition (TPN; 99.10) during the same hospitalization. Statistical analysis was conducted by χ(2) tests and Wilcoxon rank-sum comparisons.

RESULTS

Of 23,744 patients presenting with AMI, 4665 underwent interventional treatment from 2005 through 2009. Of these patients, 57.1% were female, and the mean age was 70.5 years. A total of 679 patients underwent vascular intervention; 514 (75.7%) underwent open surgery and 165 (24.3%) underwent endovascular treatment overall during the study period. The proportion of patients undergoing endovascular repair increased from 11.9% of patients in 2005 to 30.0% in 2009. Severity of comorbidities, as measured by the Charlson index, did not differ significantly between the treatment groups. Mortality was significantly more commonly associated with open revascularization compared with endovascular intervention (39.3% vs 24.9%; P = .01). Length of stay was also significantly longer in the patient group undergoing open revascularization (12.9 vs 17.1 days; P = .006). During the study time period, 14.4% of patients undergoing endovascular procedures required bowel resection compared with 33.4% for open revascularization (P < .001). Endovascular repair was also less commonly associated with requirement for TPN support (13.7% vs 24.4%; P = .025).

CONCLUSIONS

Endovascular intervention for AMI had increased significantly in the modern era. Among AMI patients undergoing revascularization, endovascular treatment was associated with decreased mortality and shorter length of stay. Furthermore, endovascular intervention was associated with lower rates of bowel resection and need for TPN. Further research is warranted to determine if increased use of endovascular repair could improve overall and gastrointestinal outcomes among patients requiring vascular repair for AMI.

Safety and efficacy outcomes of infrapopliteal endovascular procedures performed in patients with critical limb ischemia according to the Society for Vascular Surgery objective performance goals

BACKGROUND

Objective performance goals (OPGs) are a set of standardized end points generated from well documented historical controls against which new therapeutic procedures may be compared in single-arm studies. Recently, the Society for Vascular Surgery suggested a set of OPGs designed from vein bypass controls that could be used to evaluate the safety and efficacy of endovascular devices applied to critical limb ischemia through a noninferiority analysis. Our aim is to analyze the results of infrapopliteal endovascular procedures performed in patients with critical limb ischemia according to these OPG end points.

METHODS

This is a retrospective study of 121 infrapopliteal endovascular procedures. The tibial intervention was combined with a femoropopliteal angioplasty in 70 procedures. Major adverse cardiovascular events (MACEs), major adverse limb events (MALEs), and major amputations at 30 days were recorded as safety outcomes. Freedom from any MALE or perioperative death (Freedom from MALE + POD) and amputation-free survival were calculated as primary efficacy end points at both 12 months and at 8 years. The 95% confidence intervals (CIs) of all the end points were calculated to perform a noninferiority comparison using OPGs as the reference.

RESULTS

The incidence of MACEs, MALEs, and amputation at 30 days were 5% (95% CI: 2-10% [OPG-MACE <10%]), 2.5% (95% CI: 0.5-7% [OPG-MALE <9%]), and 1.7% (95% CI: 0.2-6% [OPG-major amputation <4%]), respectively. We recorded a freedom from MALE + POD of 76% (95% CI: 67-83% [OPG-MALE + POD >67%]) and an amputation-free survival of 78% (95% CI: 69-85% [OPG-amputation-free survival >68%]) at 12 months. Freedom from MALE + POD and amputation-free survival at 8 years decreased to 60% (95% CI: 49-69%) and to 26% (95% CI: 11-44%), respectively.

CONCLUSIONS

Infrapopliteal endovascular procedures performed in everyday vascular surgery practice could meet the main OPG end points proposed for catheter-based treatment of critical limb ischemia.

Unspecific clinical presentation of bowel ischemia in the very old. Digitalis treatment - a reason for higher mortality?

BACKGROUND AND AIMS

Ischemic bowel disease predominantly affects the elderly (>65 years). Early diagnosis and treatment are of vital importance for the outcome. The vague symptoms of ischemic bowel disease entail a risk of delayed diagnosis, with a subsequent risk of increased mortality. The aims of this retrospective study were to identify symptoms and prodromes, to study factors associated with mortality in ischemic bowel disease, and to describe the influence of age, by comparing patients <80 and > or = 80 years.

METHODS

The subjects of the study were 135 patients, mean age 77 years, admitted to Malmö University Hospital, Sweden, between 1987 and 1996, with a ICD-9 diagnosis of acute or chronic splanchnic ischemia.

RESULTS

Patients aged 80 years or more presented with a significantly higher prevalence of confusion (29% vs 12%), hematemesis (57% vs 14%), vomiting (82% vs 65%) and dehydration (58% vs 36%) at admission compared with patients aged under 80 years, and presented a higher mortality (87% compared with 65%, p=0.003). The prevalence of digitalis treatment was 34%, which was high compared with other Swedish cohort studies. Digitalis, adjusted for age, congestive heart failure and atrial fibrillation, was associated with increased mortality (odds ratio 4.6, 95% CI 1.3-16.1). Prodromal signs predicted poor outcome, and were found in one out of 4 patients, without any age differences.

CONCLUSIONS

Bowel ischemia in the very old is associated with a different clinical presentation and a higher mortality compared with younger patients. Digitalis treatment seems to be associated with increased mortality in ischemic bowel disease. Prodromal signs are prognostically unfavorable.

Acute limb ischemia in nonagenarians

AIM

Acute limb ischemia (ALI) is not infrequently associated with limb loss (10-30%) or death of the affected patient (15-30%). These results can be even worse in elderly population. The aim of this study is to quantify safety and efficacy of early revascularization in over 90 years old patients with acute limb ischemia.

METHODS

This is a prospective registry lasting from January 2012 to January 2013. We include all consecutive over 90 years patients treated for ALI (N.=15). A careful preoperative Duplex scan (DS) were performed in each patient. All patients underwent surgery by Fogarty's embolectomy, and endovascular completion procedure if needed (N.=3).

RESULTS

We performed 18 revascularizations (15 lower limbs, 3 upper limbs) in 15 patients (2 staged bilateral femoral, 1 simultaneous bilateral femoral). The mean follow-up was 124 days (4-365). Technical success was obtained in 16 cases (88.9%). At disharge mortality was 5.9% (1 case), and amputation rate was 6.2% (1 pt). The Kaplan-Meier curves at 1 year revealed an estimated freedom from death, amputation and re-occlusion of 76.5%, 88.2%, and 71.3%, respectively.

CONCLUSION

The over 90 years old patient represent a challenging case for vascular surgeon. Vascular procedures involve high mortality rate but emergent revascularization by Fogarty Embolectomy in ALI is safe and effective even in older patient.