Combined iliac angioplasty and infrainguinal revascularization surgery are effective in diabetic patients with multilevel arterial disease

Simultaneous Ipsilateral Infrainguinal Angioplasty and Bypass Procedures

We studied the efficacy of surgeon-performed combined ipsilateral endovascular and open arterial concomitant reconstruction at the infrainguinal level. It was a retrospective analytic study. The study included 15 patients (9 men, 6 women) who underwent 15 combined procedures between January 2000 and January 2004. They were divided into two groups. The first group consisted of nine patients with an inflow angioplasty. The second group included six patients with an outflow angioplasty. Indications for arterial reconstruction were claudication (one patient), ischemic rest pain (three patients), and gangrene (eleven patients). Immediate technical success of the combined procedures was 100%. In the first group, one patient died owing to a myocardial infarction, ischemic lesions healed in eight patients, one patient required revision of the graft and three reconstructions occluded, with one amputation of the affected limb. In the second group, one patient died owing to stoke, one patient needed a graft revision and one underwent a limb amputation. The cumulative limb salvage at 42 months was 85%. Our results suggest that simultaneous ipsilateral infrainguinal angioplasty and bypass procedures could be performed with good results. Inflow and outfow angioplasty allow using a shorter single graft segment. Outflow angioplasty ameliorates the bypass flow and accelerates the healing of ischemic lesions. The restenosis rate of the inflow angioplasty at the femoral level remains low.

Endovascular Treatment of Iliac Occlusive Disease: Review and Update

Use of endovascular interventions for arterial occlusive lesions continues to increase. With the evolution of the technology supporting these therapeutic measures, the results of these interventions continue to improve. In general, a comparison of techniques for revascularization of iliac occlusive diseases shows similar initial technical success rates for open versus percutaneous transluminal angioplasty. Angioplasty is often associated with lower periprocedural morbidity and mortality rates. Conversely, surgery frequently provides greater long-term patency, although late failure of percutaneous therapies may occur but still can be treated successfully with reintervention. The perpetual buildup of experience with angioplasty and stenting will eventually characterize its role in the management of occlusive disease. This review outlines the current consensus and applicability of endovascular management of iliac occlusive diseases.

Simultaneous hybrid peripheral re-vascularization: early results

Endovascular and open surgical interventions may be combined in treatment of peripheral arterial disease. In this study, we presented our simultaneous hybrid peripheral interventions under the light of current literature data. Eleven patients who were operated for occlusive peripheral arterial disease without aneurysms between June 2008 and November 2010 at our hybrid operating room were investigated retrospectively. Generally, endovascular intervention was performed initially, and then followed by surgery. After hybrid interventions, control angiograms were held during the same session. None of the patients experienced either stent or graft occlusion during early postoperative period. Primary patency rate was found to be 100% for the postoperative first six months. Ankle-brachial indices (ABI) increased significantly during postoperative period and clinical symptoms were relieved in all patients (mean preoperative ABI: 0.43 ± 0.08, mean postoperative sixth month ABI: 0.87 ± 0.08). Peripheral hybrid interventions may be performed both in separate sessions and also simultaneously by experienced teams if an angiography device is available within the operating room.

Combined Percutaneous Endovascular Iliac Angioplasty and Infrainguinal Surgical Revascularization for Chronic Lower Extremity Ischemia: Preliminary Result

The purpose of this study was to evaluate the efficacy of combined ipsilateral percutaneous iliac angioplasty and open infrainguinal surgical techniques for the treatment of patients with multilevel arterial occlusive disease. Combining two types of approaches in the peripheral vascular field is a less aggressive technique and may result in excellent early patency and limb salvage rates. We report our initial experience with a combined percutaneous endovascular iliac angioplasty and infrainguinal surgical reconstruction for patients with chronic lower extremity ischemia associated with multilevel arterial occlusive disease who presented with severe (disabling) lower limb claudication that significantly reduced quality of life, as well as patients with rest pain, nonhealing ulcers, and gangrene.

There were 30 patients, 20 of whom had percutaneous transluminal angioplasty (PTA) only and 10 who had PTA with a stent. The infrainguinal procedures associated with each were thromboendarterectomy with vein patch angioplasty of both the common femoral artery (CFA) (12 patients), and the popliteal artery (8 patients) and a short femoropopliteal bypass for the superficial femoral artery (SFA) after recanalization of the arterial lumen using thromboendarterectomy to shorten the bypass graft (10 patients), using a reversed saphenous vein graft. The procedures were performed from July 2007 to February 2008 at the Division of Vascular and Endovascular Surgery, Al-Hussein University Hospital (Al-Azhar Faculty of Medicine, Cairo, Egypt).

The study included 30 patients, 17 males and 13 females, with a mean age of 54 years (range 42–72) who underwent both combined ipsilateral percutaneous endovascular iliac angioplasty and open surgical treatment of both femoral (ie, the CFA or the SFA) and popliteal occlusive diseases. Indications were claudication that reduced quality of life after failure of conservative medical treatment in 14 patients (46.6%), critical limb ischemia in 8 patients (26.7%), and tissue loss, nonhealing ulcers, and gangrene in 8 patients (26.7%). Initial technical and hemodynamic success was achieved in 100% of cases. Clinical success was achieved in 96.7% of cases after 6 months, and clinical failure was observed in 3.3% of cases owing to occlusion of the short femoropopliteal bypass graft. Good hemodynamic results were observed in 74.9% of cases as the mean postoperative ankle-brachial index remained elevated to 1.03 ± 0.1 and 1.07 ± 0.12 after 3 and 6 months, respectively.

Combined vascular therapy may be used effectively in patients with chronic extremity ischemia owing to multiple levels of arterial occlusion and should be performed with good results. Technical success and early patency rates are excellent. The patients' symptoms improved and resistant ischemic ulcers healed within a short period of time.

Combined Percutaneous Endovascular Iliac Angioplasty and Infrainguinal Surgical Revascularization for Chronic Lower Extremity Ischemia: Preliminary Result

The purpose of this study was to evaluate the efficacy of combined ipsilateral percutaneous iliac angioplasty and open infrainguinal surgical techniques for the treatment of patients with multilevel arterial occlusive disease. Combining two types of approaches in the peripheral vascular field is a less aggressive technique and may result in excellent early patency and limb salvage rates. We report our initial experience with a combined percutaneous endovascular iliac angioplasty and infrainguinal surgical reconstruction for patients with chronic lower extremity ischemia associated with multilevel arterial occlusive disease who presented with severe (disabling) lower limb claudication that significantly reduced quality of life, as well as patients with rest pain, nonhealing ulcers, and gangrene.

There were 30 patients, 20 of whom had percutaneous transluminal angioplasty (PTA) only and 10 who had PTA with a stent. The infrainguinal procedures associated with each were thromboendarterectomy with vein patch angioplasty of both the common femoral artery (CFA) (12 patients), and the popliteal artery (8 patients) and a short femoropopliteal bypass for the superficial femoral artery (SFA) after recanalization of the arterial lumen using thromboendarterectomy to shorten the bypass graft (10 patients), using a reversed saphenous vein graft. The procedures were performed from July 2007 to February 2008 at the Division of Vascular and Endovascular Surgery, Al-Hussein University Hospital (Al-Azhar Faculty of Medicine, Cairo, Egypt).

The study included 30 patients, 17 males and 13 females, with a mean age of 54 years (range 42–72) who underwent both combined ipsilateral percutaneous endovascular iliac angioplasty and open surgical treatment of both femoral (ie, the CFA or the SFA) and popliteal occlusive diseases. Indications were claudication that reduced quality of life after failure of conservative medical treatment in 14 patients (46.6%), critical limb ischemia in 8 patients (26.7%), and tissue loss, nonhealing ulcers, and gangrene in 8 patients (26.7%). Initial technical and hemodynamic success was achieved in 100% of cases. Clinical success was achieved in 96.7% of cases after 6 months, and clinical failure was observed in 3.3% of cases owing to occlusion of the short femoropopliteal bypass graft. Good hemodynamic results were observed in 74.9% of cases as the mean postoperative ankle-brachial index remained elevated to 1.03 ± 0.1 and 1.07 ± 0.12 after 3 and 6 months, respectively.

Combined vascular therapy may be used effectively in patients with chronic extremity ischemia owing to multiple levels of arterial occlusion and should be performed with good results. Technical success and early patency rates are excellent. The patients' symptoms improved and resistant ischemic ulcers healed within a short period of time.

Combined percutaneous endovascular iliac angioplasty and infrainguinal surgical revascularization for chronic lower extremity ischemia: preliminary result

The purpose of this study was to evaluate the efficacy of combined ipsilateral percutaneous iliac angioplasty and open infrainguinal surgical techniques for the treatment of patients with multilevel arterial occlusive disease. Combining two types of approaches in the peripheral vascular field is a less aggressive technique and may result in excellent early patency and limb salvage rates. We report our initial experience with a combined percutaneous endovascular iliac angioplasty and infrainguinal surgical reconstruction for patients with chronic lower extremity ischemia associated with multilevel arterial occlusive disease who presented with severe (disabling) lower limb claudication that significantly reduced quality of life, as well as patients with rest pain, nonhealing ulcers, and gangrene.There were 30 patients, 20 of whom had percutaneous transluminal angioplasty (PTA) only and 10 who had PTA with a stent. The infrainguinal procedures associated with each were thromboendarterectomy with vein patch angioplasty of both the common femoral artery (CFA) (12 patients), and the popliteal artery (8 patients) and a short femoropopliteal bypass for the superficial femoral artery (SFA) after recanalization of the arterial lumen using thromboendarterectomy to shorten the bypass graft (10 patients), using a reversed saphenous vein graft. The procedures were performed from July 2007 to February 2008 at the Division of Vascular and Endovascular Surgery, Al-Hussein University Hospital (Al-Azhar Faculty of Medicine, Cairo, Egypt).The study included 30 patients, 17 males and 13 females, with a mean age of 54 years (range 42-72) who underwent both combined ipsilateral percutaneous endovascular iliac angioplasty and open surgical treatment of both femoral (ie, the CFA or the SFA) and popliteal occlusive diseases. Indications were claudication that reduced quality of life after failure of conservative medical treatment in 14 patients (46.6%), critical limb ischemia in 8 patients (26.7%), and tissue loss, nonhealing ulcers, and gangrene in 8 patients (26.7%). Initial technical and hemodynamic success was achieved in 100% of cases. Clinical success was achieved in 96.7% of cases after 6 months, and clinical failure was observed in 3.3% of cases owing to occlusion of the short femoropopliteal bypass graft. Good hemodynamic results were observed in 74.9% of cases as the mean postoperative ankle-brachial index remained elevated to 1.03 +/- 0.1 and 1.07 +/- 0.12 after 3 and 6 months, respectively.Combined vascular therapy may be used effectively in patients with chronic extremity ischemia owing to multiple levels of arterial occlusion and should be performed with good results. Technical success and early patency rates are excellent. The patients' symptoms improved and resistant ischemic ulcers healed within a short period of time.

Infection and musculoskeletal conditions: Osteomyelitis

Osteomyelitis can result from hematogenous or contiguous microbial seeding of the bone. Staphylococcus aureus is the most common infecting microorganism. Although any bone can potentially develop osteomyelitis, long-bone, vertebral, and foot osteomyelitis account for the majority of cases. Confirmatory diagnosis of osteomyelitis often depends on the results of a bone biopsy and bone cultures. Radiologic and laboratory studies are often helpful in leading to the diagnosis, determining the extent of the disease, and following up selected patients with osteomyelitis. Optimal therapy for osteomyelitis requires the collaboration of a multidisciplinary team of physicians. Debridement is often needed in contiguous osteomyelitis, whereas acute hematogenous and vertebral osteomyelitis can often be treated with a prolonged course of antimicrobial therapy.

The Influence of the Ipsilateral Superficial Femoral Artery on Iliac Angioplasty

Our objective was to evaluate the impact of the ipsilateral superficial femoral artery (SFA) on percutaneous transluminal angioplasty (PTA) of the iliac arteries. From 1993 to 2005, 183 iliac lesions (179 stenoses, 4 occlusions; 37 common, 35 external, and 111 both iliac arteries) in 127 patients with disabling claudication [94 (52%)], rest pain [43 (23%)], and ulcer/gangrene [46 (25%)] were treated by PTA. TransAtlantic Inter-Society Consensus (TASC) iliac lesion types were A in 48 limbs (26%), B in 92 (50%), C in 38 (21%), and D in 5 (3%). Stents were placed selectively for primary angioplasty failure [residual stenosis (>30%) or pressure gradient (>5 mm Hg)]. Seventy-seven limbs (42%) had patent SFAs (66 intact/<50% stenosis and 11 previously bypassed, pSFA group), 28 (15%) had stenotic SFAs (50-99%, sSFA group), 51 (28%) had occluded SFAs (oSFA group), and 27 (15%) had concomitant SFA angioplasty (aSFA group). The Society for Vascular Surgery and the International Society for Cardiovascular Surgery reporting standards were followed to define outcomes. There were no perioperative deaths. Total complication rate was 1.1% (2/183, groin hematomas). The mean follow-up was 20 months (range 1-115). One hundred twenty-five limbs (68%) had PTA alone for iliac lesions, and 58 (32%) had iliac stenting (a total of 91 stents). TASC iliac lesion types and the status of the ipsilateral profunda femoris artery were not significantly different among the four groups. Seventeen limbs (9%) had subsequent infrainguinal bypass: three in the pSFA, seven in the oSFA, four in the sSFA, and three in the aSFA groups (p = 0.19). The primary patency rate was significantly decreased in the sSFA group (29% at 3 years, Kaplan-Meier log-rank, p < 0.0001) compared with the other three groups; however, there were no significant differences among the pSFA, oSFA, and aSFA groups (67%, 67%, and 86% at 3 years, respectively; p = 0.92). The continued clinical improvement rates were significantly decreased in the sSFA group (36% at 3 years, p = 0.0043) compared with the other three groups; however, there was no significant difference between the pSFA, oSFA, and aSFA groups (81%, 84%, and 75% at 3 years, respectively; p = 0.088). The assisted primary and secondary patency and limb salvage rates were not significantly different among the four groups (p > 0.40). Stratified analysis in patients with TASC type B/type C, critical limb ischemia, or claudicants revealed similar results. The primary patency and continued clinical improvement were significantly decreased in patients with stenotic SFAs, suggesting that concomitant SFA angioplasty might improve iliac patency after iliac PTA for patients with stenotic SFAs. The presence of an occluded SFA did not adversely affect the outcomes of iliac PTA. During iliac PTA, a stenotic SFA should be considered for revascularization via endovascular means but an occluded SFA can be observed.

Osteomyelitis of the foot and toe in adults is a surgical disease: conservative management worsens lower extremity salvage

OBJECTIVE

To characterize the national epidemiology of adult osteomyelitis (OM) and, using a single institutions' experience, test the hypothesis that early surgical therapy as compared with antibiotics alone results in an improved chance of wound healing and limb salvage.

BACKGROUND

Foot and digit OM is a very common problem for which management is variable and for which few guidelines exist.

METHODS

The Nationwide Inpatient Sample (NIS) and a single institution review from 1993 to 2000 form the basis of this study, using ICD-9CM codes for lower extremity foot and digit OM. Demographics, risk factors, and treatments were analyzed against the outcomes of a healed wound, limb salvage, and death.

RESULTS

The NIS included 51,875 patients (incidence = 9/10,000 patients per year) with a mean age of 60 years, and 59% were men. The median length of stay decreased from 9 to 6 days (P < 0.001), but the average admission charge of 19,000 dollars did not significantly decrease over 7 years. Of these patients, 23% underwent a digit amputation and 8.5% suffered proximal limb loss. Single-institution analysis of 237 consecutive patients with OM confirmed a similar mean age (58 years), gender (67% men), and most presented with a foot or digit ulcer (56%). Wound healing was achieved in 56% and overall limb salvage was 80%. Decreased wound healing was associated with peripheral vascular occlusive disease (odds ratio, 0.4; 95% confidence interval, 0.2-0.8, P = 0.006) and preadmission antibiotic use (odds ratio, 0.2; 95% confidence interval, 0.05-1.1, P=0.07), while surgical debridement (odds ratio, 2.2; 95% confidence interval, 1.2-4.2, P = 0.02) was associated with increased healing. Limb salvage was improved with an arterial bypass (odds ratio, 3.9; 95% confidence interval, 1.1-14, P = 0.04), while preadmission solid organ transplant (odds ratio, 0.37; 95% confidence interval, 0.14-0.96, P = 0.04), peripheral vascular occlusive disease (odds ratio, 0.25; 95% confidence interval, 0.12-0.5, P = 0.001), and preadmission antibiotic use (odds ratio, 0.34; 95% confidence interval, 0.15-0.77, P = 0.009) were associated with greater limb loss.

CONCLUSION

Digit OM is an expensive and morbid disease. Aggressive surgical debridement/digit amputation and selected use of arterial bypass should improve wound healing and limb salvage, respectively. In contrast, antibiotic therapy alone is associated with decreased wound healing and limb salvage.

Peripheral arterial disease: clinical assessment and indications for revascularization in the patient with diabetes

Peripheral arterial disease (PAD) is an under-recognized complication of diabetes. Recently, prevalence estimates in patients with diabetes over 50 years of age have been placed at 25% to 30%. The main reason for under-reporting is the largely asymptomatic nature of PAD in diabetes. Nonetheless, it is important to diagnose PAD because it is a marker of systemic atherosclerosis with excess cardiovascular risk, and it may identify a patient who may develop progressive disability and risk of limb loss. The most sensitive and specific diagnostic tool is an ankle-brachial index. Imaging studies are performed in patients who are candidates for revascularization. The most durable and effective revascularization procedure for PAD in diabetes is surgical bypass with saphenous vein as the conduit. Endovascular interventions are best used in patients with proximal disease with short-segment stenoses. The indications for revascularization have been immutable for decades, namely rest pain, ischemic ulceration, or gangrene. Presently, clinicians would include "selected" patients with intermittent claudication who have disabling symptoms and proximal disease above the inguinal ligament.

The role of surgical revascularization in the management of diabetic foot wounds

Diabetic foot wounds affect an estimated 15% of all patients with diabetes. These wounds are typically multifactorial in origin. Neuropathy of the foot and impaired wound healing are frequently associated with peripheral arterial occlusive disease. These factors combine to contribute to the development of foot ulcers. Successful wound healing and limb salvage require prompt recognition and treatment. Assessment of arterial perfusion is imperative and may be accomplished by a combination of physical examination and noninvasive vascular laboratory studies. When associated with significant ischemia, diabetic foot ulcers require arterial revascularization to achieve wound healing.

Iliac angioplasty and stenting in association with infrainguinal bypasses: timing and techniques

Inflow iliac artery balloon angioplasty may be performed simultaneously with open infrainguinal vascular reconstruction in patients with multilevel occlusive disease of the lower extremity. This approach is safe, effective, has satisfactory long-term results, and should be part of the vascular armamentarium.

Early results of external iliac artery stenting combined with common femoral artery endarterectomy

PURPOSE

The endovascular approach to external iliac artery (EIA) disease extending into the common femoral artery (CFA) has been avoided because of problems with stent placement across the inguinal ligament. Surgical treatment for this disease distribution includes extensive endarterectomy or bypass procedures or both. We report our initial experience with a combined open and endovascular approach to these patients.

METHODS

We performed a retrospective analysis of all patients who underwent intraoperative EIA stenting after CFA endarterectomy/patch angioplasty between 1997 and 2000. Stents were positioned to end at the proximal endarterectomy endpoint, without crossing the inguinal ligament. Technical success, hemodynamic success, and clinical success were determined according to Society of Vascular Surgery/International Society of Cardiovascular Surgery criteria. Life-table analysis was performed for patency.

RESULTS

Thirty-four patients (mean age, 68 years; 23 male, 11 female) had combined endovascular and open treatment of iliofemoral occlusive disease. Indications were claudication in 41% and critical limb ischemia in 59%. Femoral reconstruction included endarterectomy with patch angioplasty in all patients. EIA stent deployment incorporated the stenotic iliac segment and the proximal endpoint of the endarterectomy in all patients. Four patients (12%) also needed common iliac angioplasty at the same time for proximal iliac disease, and 14 patients (41%) also needed distal revascularization for associated femoropopliteal or tibial disease. Technical success and hemodynamic success were achieved in 100% of patients. Clinical success was achieved in 97% of patients. The mean postoperative increase in ankle-brachial index in patients with inflow procedures only was 0.36 (range, 0.1 to 0.85). The overall complication rate was 15%. With a mean follow-up period of 13 months (range, 0.5 to 28 months), 1-year primary patency and primary-assisted patency rates were 84% and 97%, respectively. No perioperative mortality was seen.

CONCLUSION

EIA stenting as an adjunct to CFA endarterectomy/patch angioplasty allows for more localized surgery than conventional bypass. This approach also allows a better interface between the stent and endarterectomy than staged preoperative stenting. Technical success and early patency rates are excellent.