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Ozawa T, Yanishi K, Fujioka A, Seki T, Zen K, Matoba S. Comparison of Clinical Outcomes in Patients with Acute Lower Limb Ischaemia Undergoing Endovascular Therapy and Open Surgical Revascularisation: A Large Scale Analysis in Japan. Eur J Vasc Endovasc Surg 2024:S1078-5884(24)00781-0. [PMID: 39218296 DOI: 10.1016/j.ejvs.2024.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 08/01/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVE The recommended revascularisation methods for acute limb ischaemia (ALI), which is caused by embolism and atherosclerotic thrombosis, include endovascular therapy (EVT) and open surgical revascularisation (OSR); however, treatment choices based on patient characteristics remain controversial. This retrospective analysis from the Japanese Registry of All Cardiac and Vascular Diseases - Diagnosis Procedure Combination database (April 2012 to March 2020) evaluated differences in clinical outcomes and identified prognostic predictors in patients with ALI. METHODS This study analysed 10 977 patients with lower limb ALI. EVT was defined as catheter directed thrombolysis, percutaneous thrombectomy, or percutaneous angioplasty with balloon dilatation and or stenting. OSR was defined as Fogarty thrombectomy, bypass surgery, or thromboendarterectomy. The EVT and OSR groups were compared after propensity score matching (PSM) considering ten clinical covariables. RESULTS The EVT group had more patients at higher risk of atherosclerotic disease than the OSR group. The OSR group had more patients at a higher risk of embolism, including atrial fibrillation and atrial flutter, than the EVT group. In the EVT group, 20.4% of patients underwent catheter directed thrombolysis using urokinase, the only thrombolytic agent available in Japan that is covered under insurance. After PSM, in hospital mortality (odds ratio [OR] 1.33, 95% confidence interval [CI] 1.11 - 1.59; p = .002), major amputation rate (OR 1.43, 95% CI 1.19 - 1.72; p < .001), major amputation and or death rate (OR 1.42, 95% CI 1.24 - 1.62; p < .001), and total hospitalisation cost (1.16 vs. 0.97 million yen; p < .001) were statistically significantly more common in the EVT group. In interaction analyses, peripheral artery disease (PAD) was a factor responsible for reducing OSR efficacy in terms of major amputation and or death rate (with PAD, OR 0.94, 95% CI 0.68 - 1.29; without PAD, OR 1.56, 95% CI 1.34 - 1.82; p = .004). CONCLUSION In Japan, EVT was a less effective primary treatment for patients with ALI than OSR, except for those with PAD.
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Affiliation(s)
- Takaaki Ozawa
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenji Yanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Ayumu Fujioka
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kan Zen
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Lübcke J, Peters F, Acar L, Marschall U, Behrendt CA. Short Term Outcomes and Treatment Intensity of Major Cardiovascular Emergencies During the COVID-19 Pandemic in Germany. Eur J Vasc Endovasc Surg 2024; 68:82-89. [PMID: 38493960 DOI: 10.1016/j.ejvs.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 02/17/2024] [Accepted: 03/11/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVE There has been a decline in hospital admission rates in many countries since the beginning of the COVID-19 pandemic. Patient selection differed from episodes before the pandemic. This study investigated changes in baseline characteristics as well as the short term mortality rate and probability of receiving an invasive procedure while considering sex disparities. METHODS Claims data provided by Germany's second largest insurance fund, BARMER, were used. Patients without COVID-19 who were treated for ST segment elevation myocardial infarction (STEMI), non-ST segment elevation myocardial infarction (NSTEMI), acute limb ischaemia (ALI), and stroke between 1 January 2018 and 31 December 2021 were included. Outcomes were compared separately for both sexes between the years before the pandemic (2018/2019) and during the pandemic (2020/2021). Propensity scores with exact matching were used to balance confounders including age, drug prescriptions in the previous year, federal state, month of admission, domiciliary care, and the Elixhauser comorbidities. Short term death and probability of invasive procedures were determined using cumulative incidence functions and Cox regressions. RESULTS The cohort consisted of 140 989 hospitalisations of 122 340 individual patients (48.3% female) with 102 960 matched cases. Baseline characteristics were similar between episodes in the unmatched cohort. Earlier discharge was observed for all strata except for males with ALI or STEMI, where the probability of early discharge was unchanged. The probability of receiving an invasive procedure was increased for both sexes with ALI, NSTEMI, and STEMI but not for stroke. The analyses suggested neither a statistically significant increase of the in hospital mortality rate nor the 30 day mortality rate after the pandemic started. CONCLUSION There was no evidence for a direct or indirect impact of the pandemic on major short term hospital outcomes. While the probability of receiving an invasive procedure increased for STEMI, NSTEMI, and ALI, the overall short term mortality rate was unaffected for both sexes.
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Affiliation(s)
- Jenny Lübcke
- Research Group GermanVasc, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | - Christian-Alexander Behrendt
- Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany; Medical School Brandenburg Theodor-Fontane, Neuruppin, Germany.
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Sun XX, Ling H, Zhang L, Chen RB, Zhong AQ, Feng LQ, Yu R, Chen Y, Liu JQ. Development and validation of a risk prediction model and prediction tools for post-thrombotic syndrome in patients with lower limb deep vein thrombosis. Int J Med Inform 2024; 187:105468. [PMID: 38703744 DOI: 10.1016/j.ijmedinf.2024.105468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/21/2024] [Accepted: 04/24/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Our research aims to compare the predictive performance of decision tree algorithms (DT) and logistic regression analysis (LR) in constructing models, and develop a Post-Thrombotic Syndrome (PTS) risk stratification tool. METHODS We retrospectively collected and analyzed relevant case information of 618 patients diagnosed with DVT from January 2012 to December 2021 in three different tertiary hospitals in Jiangxi Province as the modeling group. Additionally, we used the case information of 212 patients diagnosed with DVT from January 2022 to January 2023 in two tertiary hospitals in Hubei Province and Guangdong Province as the validation group. We extracted electronic medical record information including general patient data, medical history, laboratory test indicators, and treatment data for analysis. We established DT and LR models and compared their predictive performance using receiver operating characteristic (ROC) curves and confusion matrices. Internal and external validations were conducted. Additionally, we utilized LR to generate nomogram charts, calibration curves, and decision curves analysis (DCA) to assess its predictive accuracy. RESULTS Both DT and LR models indicate that Year, Residence, Cancer, Varicose Vein Operation History, DM, and Chronic VTE are risk factors for PTS occurrence. In internal validation, DT outperforms LR (0.962 vs 0.925, z = 3.379, P < 0.001). However, in external validation, there is no significant difference in the area under the ROC curve between the two models (0.963 vs 0.949, z = 0.412, P = 0.680). The validation results of calibration curves and DCA demonstrate that LR exhibits good predictive accuracy and clinical effectiveness. A web-based calculator software of nomogram (https://sunxiaoxuan.shinyapps.io/dynnomapp/) was utilized to visualize the logistic regression model. CONCLUSIONS The combination of decision tree and logistic regression models, along with the web-based calculator software of nomogram, can assist healthcare professionals in accurately assessing the risk of PTS occurrence in individual patients with lower limb DVT.
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Affiliation(s)
- Xiao-Xuan Sun
- Nursing Department, the 1(st) affiliated hospital, Jiangxi Medical College, Nanchang University, 330000, China; School of Nursing, Jiangxi Medical College, Nanchang University, 330000, China.
| | - Hua Ling
- Nursing Department, the 1(st) affiliated hospital, Jiangxi Medical College, Nanchang University, 330000, China; School of Nursing, Jiangxi Medical College, Nanchang University, 330000, China.
| | - Lei Zhang
- School of the First Clinical Medical, Jiangxi Medical College, Nanchang University, 330000, China; Cardiovascular medicine department,the 1(st) affiliated hospital, Jiangxi Medical College, Nanchang University, 330000, China.
| | - Rui-Bin Chen
- Information Office of the 1(st) affiliated hospital, Jiangxi Medical College, Nanchang University, 330000, China.
| | - An-Qi Zhong
- School of Life Science and TechnologyJiangsu University Jingjiang College, 212013, China.
| | - Li-Qun Feng
- Department of Vascular Surgery of the 1(st) affiliated hospital, Jiangxi Medical College, Nanchang University, 330000, China.
| | - Ran Yu
- Nursing Department, the 1(st) affiliated hospital, Jiangxi Medical College, Nanchang University, 330000, China; School of Nursing, Jiangxi Medical College, Nanchang University, 330000, China.
| | - Ying Chen
- Nursing Department, the 1(st) affiliated hospital, Jiangxi Medical College, Nanchang University, 330000, China; School of Nursing, Jiangxi Medical College, Nanchang University, 330000, China.
| | - Jia-Qiu Liu
- Nursing Department, the 1(st) affiliated hospital, Jiangxi Medical College, Nanchang University, 330000, China; School of Nursing, Jiangxi Medical College, Nanchang University, 330000, China.
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Pelletier J, Koyfman A, Long B. Acute aortic occlusion: A narrative review for emergency clinicians. Am J Emerg Med 2024; 79:192-197. [PMID: 38460466 DOI: 10.1016/j.ajem.2024.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 03/11/2024] Open
Abstract
INTRODUCTION Acute aortic occlusion (AAO) is a rare but serious condition associated with significant morbidity and mortality. OBJECTIVE This review provides an emergency medicine focused evaluation of AAO, including presentation, assessment, and emergency department (ED) management based on current evidence. DISCUSSION AAO refers to obstruction of blood flow through the aorta due to either thrombosis or embolism. This condition primarily affects older adults ages 60-70 with cardiovascular comorbidities and most commonly presents with signs and symptoms of acute limb ischemia, though the gastrointestinal tract, kidneys, and spinal cord may be affected. The first line imaging modality includes computed tomography angiography of the chest, abdomen, and pelvis. ED resuscitative management consists of avoiding extremes of blood pressure or heart rate, maintaining normal oxygen saturation and euvolemic status, anticoagulation with heparin, and pain control. Emergent consultation with the vascular surgery specialist is recommended to establish a plan for restoration of perfusion to ischemic tissues via endovascular or open techniques. High rates of baseline comorbidities present in the affected population as well as ischemic and reperfusion injuries place AAO patients at high risk for complications in an immediate and delayed fashion after surgical management. CONCLUSIONS An understanding of AAO can assist emergency clinicians in diagnosing and managing this rare but devastating disease.
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Affiliation(s)
- Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- SAUSHEC, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Crupi L, Ardizzone A, Calapai F, Scuderi SA, Benedetto F, Esposito E, Capra AP. The Impact of COVID-19 on Amputation and Mortality Rates in Patients with Acute Limb Ischemia: A Systematic Review and Meta-Analysis. Diseases 2024; 12:74. [PMID: 38667532 PMCID: PMC11048752 DOI: 10.3390/diseases12040074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/02/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024] Open
Abstract
Since the inception of the SARS-CoV-2 pandemic, healthcare systems around the world observed an increased rate of Acute Limb Ischemia (ALI) in patients with a COVID-19 infection. Despite several pieces of evidence suggesting that COVID-19 infection may also worsen the prognosis associated with ALI, only a small number of published studies include a direct comparison regarding the outcomes of both COVID-19 and non-COVID-19 ALI patients. Based on the above, a systematic review and a meta-analysis of the literature were conducted, evaluating differences in the incidence of two major outcomes (amputation and mortality rate) between patients concurrently affected by COVID-19 and negative ALI subjects. PubMed (MEDLINE), Web of Science, and Embase (OVID) databases were scrutinized from January 2020 up to 31 December 2023, and 7906 total articles were recovered. In total, 11 studies (n: 15,803 subjects) were included in the systematic review, and 10 of them (15,305 patients) were also included in the meta-analysis. Across all the studies, COVID-19-positive ALI patients experienced worse outcomes (mortality rates ranging from 6.7% to 47.2%; amputation rates ranging from 7.0% to 39.1%) compared to non-infected ALI patients (mortality rates ranging from 3.1% to 16.7%; amputation rates ranging from 2.7% to 18%). Similarly, our meta-analysis shows that both the amputation rate (OR: 2.31; 95% CI: 1.68-3.17; p < 0.00001) and mortality (OR: 3.64; 95% CI: 3.02-4.39; p < 0.00001) is significantly higher in COVID-19 ALI patients compared to ALI patients.
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Affiliation(s)
- Lelio Crupi
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, 31, 98166 Messina, Italy; (L.C.); (A.A.); (F.C.); (S.A.S.); (A.P.C.)
| | - Alessio Ardizzone
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, 31, 98166 Messina, Italy; (L.C.); (A.A.); (F.C.); (S.A.S.); (A.P.C.)
| | - Fabrizio Calapai
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, 31, 98166 Messina, Italy; (L.C.); (A.A.); (F.C.); (S.A.S.); (A.P.C.)
- Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy
| | - Sarah Adriana Scuderi
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, 31, 98166 Messina, Italy; (L.C.); (A.A.); (F.C.); (S.A.S.); (A.P.C.)
| | - Filippo Benedetto
- Unit of Vascular Surgery, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Policlinico G. Martino, University of Messina, 98125 Messina, Italy;
| | - Emanuela Esposito
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, 31, 98166 Messina, Italy; (L.C.); (A.A.); (F.C.); (S.A.S.); (A.P.C.)
| | - Anna Paola Capra
- Department of Chemical, Biological, Pharmaceutical and Environmental Sciences, University of Messina, Viale Ferdinando Stagno D’Alcontres, 31, 98166 Messina, Italy; (L.C.); (A.A.); (F.C.); (S.A.S.); (A.P.C.)
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Paradis S, Charles AL, Giannini M, Meyer A, Lejay A, Talha S, Laverny G, Charloux A, Geny B. Targeting Mitochondrial Dynamics during Lower-Limb Ischemia Reperfusion in Young and Old Mice: Effect of Mitochondrial Fission Inhibitor-1 (mDivi-1). Int J Mol Sci 2024; 25:4025. [PMID: 38612835 PMCID: PMC11012338 DOI: 10.3390/ijms25074025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 03/25/2024] [Accepted: 04/01/2024] [Indexed: 04/14/2024] Open
Abstract
Peripheral arterial disease (PAD) strikes more than 200 million people worldwide and has a severe prognosis by potentially leading to limb amputation and/or death, particularly in older patients. Skeletal muscle mitochondrial dysfunctions and oxidative stress play major roles in this disease in relation with ischemia-reperfusion (IR) cycles. Mitochondrial dynamics through impairment of fission-fusion balance may contribute to skeletal muscle pathophysiology, but no data were reported in the setting of lower-limb IR despite the need for new therapeutic options. We, therefore, investigated the potential protective effect of mitochondrial division inhibitor-1 (mDivi-1; 50 mg/kg) in young (23 weeks) and old (83 weeks) mice submitted to two-hour ischemia followed by two-hour reperfusion on systemic lactate, muscle mitochondrial respiration and calcium retention capacity, and on transcripts specific for oxidative stress and mitochondrial dynamics. At the systemic levels, an IR-related increase in circulating lactate was still major despite mDivi-1 use (+305.9% p < 0.0001, and +269.4% p < 0.0001 in young and old mice, respectively). Further, IR-induced skeletal muscle mitochondrial dysfunctions (more severely impaired mitochondrial respiration in old mice (OXPHOS CI state, -68.2% p < 0.0001 and -84.9% p < 0.0001 in 23- and 83-week mice) and reduced calcium retention capacity (-46.1% p < 0.001 and -48.2% p = 0.09, respectively) were not corrected by mDivi-1 preconditioning, whatever the age. Further, mDivi-1 treatment did not oppose superoxide anion production (+71.4% p < 0.0001 and +37.5% p < 0.05, respectively). At the transcript level, markers of antioxidant enzymes (SOD 1, SOD 2, catalase, and GPx) and fission markers (Drp1, Fis) remained unchanged or tended to be decreased in the ischemic leg. Fusion markers such as mitofusin 1 or 2 decreased significantly after IR in both groups. In conclusion, aging enhanced the deleterious effects or IR on muscle mitochondrial respiration, and in this setting of lower-limb IR, mDivi-1 failed to protect the skeletal muscle both in young and old mice.
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Affiliation(s)
- Stéphanie Paradis
- Biomedicine Research Center of Strasbourg (CRBS), UR 3072, “Mitochondria, Oxidative Stress and Muscle Plasticity”, Faculty of Medicine, University of Strasbourg, 67081 Strasbourg, France; (S.P.); (A.-L.C.); (M.G.); (A.M.); (A.L.); (S.T.); (A.C.)
- Department of Physiology and Functional Explorations, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Anne-Laure Charles
- Biomedicine Research Center of Strasbourg (CRBS), UR 3072, “Mitochondria, Oxidative Stress and Muscle Plasticity”, Faculty of Medicine, University of Strasbourg, 67081 Strasbourg, France; (S.P.); (A.-L.C.); (M.G.); (A.M.); (A.L.); (S.T.); (A.C.)
| | - Margherita Giannini
- Biomedicine Research Center of Strasbourg (CRBS), UR 3072, “Mitochondria, Oxidative Stress and Muscle Plasticity”, Faculty of Medicine, University of Strasbourg, 67081 Strasbourg, France; (S.P.); (A.-L.C.); (M.G.); (A.M.); (A.L.); (S.T.); (A.C.)
- Department of Physiology and Functional Explorations, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Alain Meyer
- Biomedicine Research Center of Strasbourg (CRBS), UR 3072, “Mitochondria, Oxidative Stress and Muscle Plasticity”, Faculty of Medicine, University of Strasbourg, 67081 Strasbourg, France; (S.P.); (A.-L.C.); (M.G.); (A.M.); (A.L.); (S.T.); (A.C.)
- Department of Physiology and Functional Explorations, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Anne Lejay
- Biomedicine Research Center of Strasbourg (CRBS), UR 3072, “Mitochondria, Oxidative Stress and Muscle Plasticity”, Faculty of Medicine, University of Strasbourg, 67081 Strasbourg, France; (S.P.); (A.-L.C.); (M.G.); (A.M.); (A.L.); (S.T.); (A.C.)
- Vascular Surgery Department, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Samy Talha
- Biomedicine Research Center of Strasbourg (CRBS), UR 3072, “Mitochondria, Oxidative Stress and Muscle Plasticity”, Faculty of Medicine, University of Strasbourg, 67081 Strasbourg, France; (S.P.); (A.-L.C.); (M.G.); (A.M.); (A.L.); (S.T.); (A.C.)
- Department of Physiology and Functional Explorations, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Gilles Laverny
- Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), 67400 Illkirch, France;
| | - Anne Charloux
- Biomedicine Research Center of Strasbourg (CRBS), UR 3072, “Mitochondria, Oxidative Stress and Muscle Plasticity”, Faculty of Medicine, University of Strasbourg, 67081 Strasbourg, France; (S.P.); (A.-L.C.); (M.G.); (A.M.); (A.L.); (S.T.); (A.C.)
- Department of Physiology and Functional Explorations, University Hospital of Strasbourg, 67000 Strasbourg, France
| | - Bernard Geny
- Biomedicine Research Center of Strasbourg (CRBS), UR 3072, “Mitochondria, Oxidative Stress and Muscle Plasticity”, Faculty of Medicine, University of Strasbourg, 67081 Strasbourg, France; (S.P.); (A.-L.C.); (M.G.); (A.M.); (A.L.); (S.T.); (A.C.)
- Department of Physiology and Functional Explorations, University Hospital of Strasbourg, 67000 Strasbourg, France
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Earnshaw JJ, Björck M. Oxygen Supplementation in Acute Limb Ischaemia? Eur J Vasc Endovasc Surg 2024; 67:693. [PMID: 38056521 DOI: 10.1016/j.ejvs.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/01/2023] [Indexed: 12/08/2023]
Affiliation(s)
| | - Martin Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
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Nana P, Dakis K, Spanos K, Tsolaki V, Karavidas N, Zakynthinos G, Kouvelos G, Giannoukas A, Matsagkas M. COVID-19 related peripheral arterial thrombotic events in intensive care unit and non-intensive care unit patients: A retrospective case series. Vascular 2024; 32:366-373. [PMID: 36395575 PMCID: PMC9679328 DOI: 10.1177/17085381221140159] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
OBJECTIVES COVID-19 associated arterial thrombosis has been attributed to multiple inflammation and coagulation mechanisms. The aim of this study was to report the experience of a tertiary center on COVID-19 patients managed for acute peripheral arterial thrombosis. METHODS A single-center case series was conducted, including retrospectively collected data from all COVID-19 patients presenting arterial thrombosis, from March 2020 to February 2022. Intensive care unit (ICU) and non-ICU cases were included. The primary outcomes were mortality, successful revascularization, and amputation at 30 days. RESULTS Twenty patients presented peripheral arterial thrombosis (90% males, mean age 65 years (16-82 years)). Eighteen were diagnosed with the Delta variant and none was previously vaccinated. All cases presented acute lower limb ischemia; in 20% with bilateral involvement. Nine patients were hospitalized in the ward while 11 in the ICU. From the non-ICU cases, five presented Rutherford IIb and four cases, Rutherford's IIa ischemia. Six cases underwent revascularization (67%). Two of them were finally amputated (33%) and two died during hospitalization (33%). Two revascularizations were considered successful (33%). The ICU group presented mainly with Rutherford's III ischemia (54.5%). The mortality in the ICU cohort was 72.7%. Only one patient underwent successful revascularization and two were amputated in this subgroup. Early mortality was 50% for the total cohort while the type of management was not related to mortality. CONCLUSIONS Covid-19 related arterial thrombosis in non-vaccinated population is associated with 50% early mortality; increased up to 72% in the ICU patients. The amputation rate was 20% while only 40% of the revascularizations were considered successful.
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Affiliation(s)
- Petroula Nana
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Dakis
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Vasiliki Tsolaki
- Intensive Care Unit, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Nikitas Karavidas
- Intensive Care Unit, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Zakynthinos
- Intensive Care Unit, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Espitia O, Del Giudice C, Hartung O, Herquelot E, Schmidt A, Sapoval M, Sobocinski J. Editor's Choice -- Survival, Limb Salvage, and Management of Patients with Lower Limb Acute Ischaemia: A French National Retrospective Observational Study. Eur J Vasc Endovasc Surg 2024; 67:631-642. [PMID: 37926151 DOI: 10.1016/j.ejvs.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/22/2023] [Accepted: 11/01/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE The aim was to describe the baseline characteristics of French patients referred with acute limb ischaemia (ALI), and their clinical management and outcome (death, amputation). METHODS This retrospective observational cohort study used the National Health Data System. All adults hospitalised for ALI who underwent revascularisation with an endovascular or open surgical approach between 1 January 2015 and 31 December 2020 were included and followed up until death or the end of the study (31 December 2021). A one year look back period was used to capture patients' medical history. The risks of death, and major and minor amputations were described using Kaplan-Meier and Aalen-Johansen estimators. A Cox model was used to report the adjusted association between groups and risk of death and Fine-Gray models for the risk of amputations considering the competing risk of death. RESULTS Overall, 51 390 patients (median age 70 years, 69% male) were included and had a median follow up of 2.7 years: 39 411 (76.7%) were treated with an open approach and 11 979 (23.3%) with a percutaneous endovascular approach. The preferred approach for the revascularisation varied between French regions. The one year overall survival was 78.0% and 85.2% in the surgery and endovascular groups, respectively. The surgery group had a higher risk of death (hazard ratio [HR] 1.17, 95% CI 1.12 - 1.21), a higher risk of major amputation (sub-distribution HR 1.20, 95% CI 1.10 - 1.30) and lower risk of minor amputation (sub-distribution HR 0.66, 95% CI 0.60 - 0.71) than the endovascular group. Diabetes and dialysis increased the risk of major amputation by 52% and 78%, respectively. Subsequent ALI was the third most common cause of hospital re-admission within one year. CONCLUSION ALI remains a condition at high risk of death and amputation. Individual risk factors and ALI severity need to be considered to choose between approaches. Continued prevention efforts, improved management, and access to the most suitable approach are necessary.
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Affiliation(s)
- Olivier Espitia
- Nantes Université, CHU Nantes, Department of internal and vascular medicine, F-44000 Nantes, France.
| | | | - Olivier Hartung
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Nord, Marseille, France
| | | | | | - Marc Sapoval
- Radiologie interventionnelle, Hôpital Européen Georges-Pompidou, Paris, France
| | - Jonathan Sobocinski
- Chirurgie vasculaire et endovasculaire, Centre Hospitalier Universitaire de Lille, Lille, France
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10
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Boutonnet L, Mallard J, Charles AL, Hucteau E, Gény B, Lejay A, Grandperrin A. Autologous mitochondrial transplantation in male mice as a strategy to prevent deleterious effects of peripheral ischemia-reperfusion. Am J Physiol Cell Physiol 2024; 326:C449-C456. [PMID: 38145293 DOI: 10.1152/ajpcell.00639.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 12/26/2023]
Abstract
Ischemia-reperfusion (IR) is known to induce severe tissue damage, notably through mitochondrial dysfunction. Mitochondrial transplantation has emerged as a promising therapeutic strategy in cardiac IR; however, few studies have previously assessed its efficacy in the context of peripheral IR. Therefore, the objective of this study was to assess the effect of mitochondrial transplantation in a hindlimb model of IR injury. Thirty-six SWISS mice were divided into three groups: control (CTL, n = 12), ischemia-reperfusion (IR, n = 12), and IR with mitochondrial transplantation (MT, n = 12). Ischemia (2 h) was induced using the tourniquet model around the right hind limb in the IR and MT groups. In MT group, mitochondria isolated from the right rectus muscle, a nonischemic region, were injected shortly before reperfusion. Mitochondrial respiration, calcium retention capacity, and Western blotting analysis were performed 2 h after reperfusion. Compared with the CTL group, IR led to a decrease in the mitochondrial respiratory capacity, particularly for the basal state (-30%; P = 0.015), oxidative phosphorylation (-36%; P = 0.024), and calcium retention capacity (-45%; P = 0.007). Interestingly, mitochondrial transplantation partially restored these functions since no differences between MT and CTL groups were found. In addition, the administration of healthy mitochondria resulted in a positive regulation of redox balance and mitochondrial dynamics within the skeletal muscle. Although further investigations are needed to better characterize underlying mechanisms, mitochondrial transplantation represents a promising strategy in the setting of IR-induced muscular damage.NEW & NOTEWORTHY Ischemia-reperfusion injury leads to severe muscular damage. Even if prompt revascularization is the treatment of choice, muscular alterations can lead to severe sequalae as mitochondrial dysfunction. Accordingly, adjunctive strategies are needed to overcome the muscular damage. Mitochondrial transplantation has shown beneficial effects in cardiac ischemia-reperfusion, but its role in peripheral muscle is not well established. In this study, we found that mitochondrial transplantation partially restored muscular function when submitted to ischemia reperfusion.
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Affiliation(s)
- Lauréline Boutonnet
- Mitochondria, Oxidative Stress and Muscular Protection Laboratory (UR 3072), Biomedicine Research Centre of Strasbourg CRBS, Strasbourg, France
| | - Joris Mallard
- Mitochondria, Oxidative Stress and Muscular Protection Laboratory (UR 3072), Biomedicine Research Centre of Strasbourg CRBS, Strasbourg, France
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France
- Faculty of Sports Science, University of Strasbourg, Strasbourg, France
| | - Anne-Laure Charles
- Mitochondria, Oxidative Stress and Muscular Protection Laboratory (UR 3072), Biomedicine Research Centre of Strasbourg CRBS, Strasbourg, France
- Faculty of Medicine, University of Strasbourg, Strasbourg, France
| | - Elyse Hucteau
- Mitochondria, Oxidative Stress and Muscular Protection Laboratory (UR 3072), Biomedicine Research Centre of Strasbourg CRBS, Strasbourg, France
- Institut de Cancérologie Strasbourg Europe (ICANS), Strasbourg, France
- Faculty of Sports Science, University of Strasbourg, Strasbourg, France
| | - Bernard Gény
- Mitochondria, Oxidative Stress and Muscular Protection Laboratory (UR 3072), Biomedicine Research Centre of Strasbourg CRBS, Strasbourg, France
- Faculty of Medicine, University of Strasbourg, Strasbourg, France
- Department of Physiology and Functional Explorations, University Hospital of Strasbourg, Strasbourg, France
| | - Anne Lejay
- Mitochondria, Oxidative Stress and Muscular Protection Laboratory (UR 3072), Biomedicine Research Centre of Strasbourg CRBS, Strasbourg, France
- Faculty of Medicine, University of Strasbourg, Strasbourg, France
- Department of Vascular Surgery and Kidney Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Antoine Grandperrin
- Mitochondria, Oxidative Stress and Muscular Protection Laboratory (UR 3072), Biomedicine Research Centre of Strasbourg CRBS, Strasbourg, France
- Faculty of Sports Science, University of Strasbourg, Strasbourg, France
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11
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Nordanstig J, Behrendt CA, Baumgartner I, Belch J, Bäck M, Fitridge R, Hinchliffe R, Lejay A, Mills JL, Rother U, Sigvant B, Spanos K, Szeberin Z, van de Water W, Antoniou GA, Björck M, Gonçalves FB, Coscas R, Dias NV, Van Herzeele I, Lepidi S, Mees BME, Resch TA, Ricco JB, Trimarchi S, Twine CP, Tulamo R, Wanhainen A, Boyle JR, Brodmann M, Dardik A, Dick F, Goëffic Y, Holden A, Kakkos SK, Kolh P, McDermott MM. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Asymptomatic Lower Limb Peripheral Arterial Disease and Intermittent Claudication. Eur J Vasc Endovasc Surg 2024; 67:9-96. [PMID: 37949800 DOI: 10.1016/j.ejvs.2023.08.067] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/14/2023] [Indexed: 11/12/2023]
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12
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Puvvala GK, Psyllas A, Hinkelmann J, Herzenstiel D, Korosoglou G. Endovascular clot removal in small and tortuous arteries: a case series. Ther Adv Cardiovasc Dis 2024; 18:17539447241271989. [PMID: 39245988 PMCID: PMC11382243 DOI: 10.1177/17539447241271989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 07/02/2024] [Indexed: 09/10/2024] Open
Abstract
Acute limb ischemia (ALI) due to arterial thromboembolic occlusion is a critical emergency in vascular medicine, requiring attention for rapid diagnosis and intervention, to prevent limb loss and major amputation, which is associated with patient disability in the long term. Traditionally, surgical embolectomy has been used for the treatment of ALI. Endovascular treatment of ALI traditionally involved catheter-directed thrombolysis. This option, however, poses some limitations, including an increased risk for access site and systemic bleeding complications, especially in patients with high bleeding risk. Therefore, in the last decades, several devices have been developed and tested for the mechanical endovascular treatment of ALI. Such devices involve either rotational thrombectomy or continuous thrombus aspiration. While rotational thrombectomy is limited in rather large arteries due to the risk of dissection and perforation in arteries <3 mm, continuous thrombus aspiration can be applied in smaller vessels and tortuous anatomies. In our case series we present a minimal-invasive endovascular approach for the treatment of two patients with ALI due to thrombotic occlusion of tortious and small diameter arteries. Minimal-invasive mechanical thrombectomy using the Penumbra Aspiration System emerged as a successful alternative to surgical embolectomy, enabling prompt treatment and with a short hospital stay for both patients. Our article therefore highlights the use of continuous thrombus aspiration in small diameter vessels and tortuous anatomies, which may represent a contraindication for the use of rotational thrombectomy. In addition, this technique may be applied even in patients with higher bleeding risk since additional lysis is not necessary in patients, where complete thrombus removal can be achieved by this device.
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Affiliation(s)
| | | | | | - Daniel Herzenstiel
- Department of Cardiology and Vascular Medicine, GRN-Klink Eberbach, Eberbach, Germany
| | - Grigorios Korosoglou
- Department of Cardiology and Vascular Medicine, GRN Hospital Weinheim, Roentgenstrasse 1, Weinheim D-69469, Germany
- Department of Cardiology and Vascular Medicine, GRN-Klinik Eberbach, Eberbach, Germany
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13
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Boyle JR, Björck M. EJVES 2024 Stability and Development for a Bright Future. Eur J Vasc Endovasc Surg 2024; 67:1-2. [PMID: 38102062 DOI: 10.1016/j.ejvs.2023.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Jonathan R Boyle
- Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK.
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
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14
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Potpara T, Angiolillo DJ, Bikdeli B, Capodanno D, Cole O, Yataco AC, Dan GA, Harrison S, Iaccarino JM, Moores LK, Ntaios G, Lip GYH. Antithrombotic Therapy in Arterial Thrombosis and Thromboembolism in COVID-19: An American College of Chest Physicians Expert Panel Report. Chest 2023; 164:1531-1550. [PMID: 37392958 DOI: 10.1016/j.chest.2023.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 07/03/2023] Open
Abstract
BACKGROUND Evidence increasingly shows that the risk of thrombotic complications in COVID-19 is associated with a hypercoagulable state. Several organizations have released guidelines for the management of COVID-19-related coagulopathy and prevention of VTE. However, an urgent need exists for practical guidance on the management of arterial thrombosis and thromboembolism in this setting. RESEARCH QUESTION What is the current available evidence informing the prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19? STUDY DESIGN AND METHODS A group of approved panelists developed key clinical questions by using the Population, Intervention, Comparator, and Outcome (PICO) format that address urgent clinical questions regarding prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19. Using MEDLINE via PubMed, a literature search was conducted and references were screened for inclusion. Data from included studies were summarized and reviewed by the panel. Consensus for the direction and strength of recommendations was achieved using a modified Delphi survey. RESULTS The review and analysis of the literature based on 11 PICO questions resulted in 11 recommendations. Overall, a low quality of evidence specific to the population with COVID-19 was found. Consequently, many of the recommendations were based on indirect evidence and prior guidelines in similar populations without COVID-19. INTERPRETATION The existing evidence and panel consensus do not suggest a major departure from the management of arterial thrombosis according to recommendations predating the COVID-19 pandemic. Data on the optimal strategies for prevention and management of arterial thrombosis and thromboembolism in patients with COVID-19 are sparse. More high-quality evidence is needed to inform management strategies in these patients.
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Affiliation(s)
- Tatjana Potpara
- School of Medicine, University of Belgrade, Belgrade, Serbia; Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia.
| | | | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Yale/YNHH Center for Outcomes Research & Evaluation, New Haven, CT; Cardiovascular Research Foundation, New York, NY
| | - Davide Capodanno
- Azienda Ospedalielo-Universitaria Policlinico "G- Rodolico-San Marco", University of Catania, Catania, Italy
| | - Oana Cole
- Liverpool Heart and Chest Hospital, Liverpool, England
| | - Angel Coz Yataco
- Departments of Critical Care and of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Gheorghe-Andrei Dan
- "Carol Davila" University of Medicine, Colentina University Hospital, Bucharest, Romania
| | - Stephanie Harrison
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, England
| | - Jonathan M Iaccarino
- The Pulmonary Center, Boston University School of Medicine, Boston, MA; American College of Chest Physicians, Glenview, IL
| | - Lisa K Moores
- The Uniformed Services University of the Health Sciences, Bethesda, MD
| | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool, England; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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15
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Pawar P, Jha M, Samuel V, Stephen E, George RK. COVID Related Acute Limb Ischaemia: Data from India. Eur J Vasc Endovasc Surg 2023; 66:881-882. [PMID: 37660750 DOI: 10.1016/j.ejvs.2023.08.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/15/2023] [Accepted: 08/29/2023] [Indexed: 09/05/2023]
Affiliation(s)
- Pranay Pawar
- Vascular Surgery Unit, Christian Medical College and Hospital, Ludhiana, India, Punjab, India.
| | - Manvendu Jha
- Vascular Surgery Unit, Christian Medical College and Hospital, Ludhiana, India, Punjab, India
| | - Vimalin Samuel
- Vascular Surgery Unit, Christian Medical College and Hospital, Ludhiana, India, Punjab, India
| | - Edwin Stephen
- Vascular Surgery Unit, Christian Medical College and Hospital, Ludhiana, India, Punjab, India
| | - Robbie K George
- Vascular Surgery Unit, Christian Medical College and Hospital, Ludhiana, India, Punjab, India
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16
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Konstantinou N, Argyriou A, Dammer F, Bisdas T, Chlouverakis G, Torsello G, Tsilimparis N, Stavroulakis K. Outcomes After Open Surgical, Hybrid, and Endovascular Revascularization for Acute Limb Ischemia. J Endovasc Ther 2023:15266028231210232. [PMID: 38009372 DOI: 10.1177/15266028231210232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
PURPOSE To report the performance of surgical treatment (ST), hybrid treatment (HT), and endovascular treatment (ET) for patients with acute limb ischemia (ALI). METHODS This is a retrospective, comparative study of all consecutive patients with ALI treated in 2 tertiary centers between April 2010 and April 2020. Amputation and/or death (amputation-free survival; AFS) was the primary composite endpoint. Mortality, major amputation, and reintervention during follow-up were additionally analyzed. Proportional hazards modeling was used to identify confounders, results are presented as hazard ratio (HR) and 95% confidence intervals (CIs). RESULTS In total, 395 patients (mean age=71.1±13.6 years; 51.1% female) were treated during the study period. Surgical treatment was preferred in 150 patients (38%), while 98 were treated by HT (24.8%) and 147 by ET (37.2%). Rutherford class IIa was the most common clinical presentation in the ET group (50.3%), whereas Rutherford IIb was most common in the ST (54%) and HT (48%) groups (p<0.001). Significantly, more patients presented with a de novo lesion in the ST and HT groups (79.3% and 64.3%, respectively) compared with ET (53.7%; p<0.001). Median follow-up was 20 months (range=0-111 months). In the multivariate analysis, ET showed significantly better AFS during follow-up compared with ST (HR=1.89, 95% CI=1.2-2.9, p<0.001) and HT (HR=1.73, 95% CI=1.1-3.1, p<0.001). Mortality during follow-up was also significantly lower after ET compared with ST (HR=2.21, 95% CI=1.31-3.74, p=0.003) and HT (HR=2.04, 95% CI=1.17-3.56, p=0.012). Endovascular treatment was associated with lower amputation rate compared with ST (HR=2.27, 95% CI=1.19-4.35, p=0.013) but was comparable with HT (HR=2.00, 95% CI=0.98-4.06, p=0.055). Reintervention rates did not differ significantly between the groups (ET vs ST: HR=1.52, 95% CI=0.99-2.31, p=0.053; ET vs HT: HR=1.3, 95% CI=0.81-2.07, p=0.27). CONCLUSION Endovascular treatment for ALI was associated with improved AFS and comparable reintervention rates compared with open surgical and hybrid therapy. CLINICAL IMPACT Treatment of acute lower limb ischemia remains a challenge for clinicians with high morbidity and mortality rates. Endovascular revascularization is considered first line treatment for many and hybrid treatments are becoming more common, however data is limited to either old trials, small series or with short follow-up. We present herein our 10-year experience with all available devices and techniques for open surgical, endovascular and hybrid acute limb ischemia treatments and compare their outcomes.
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Affiliation(s)
| | - Angeliki Argyriou
- Department of Vascular Surgery, Marien Hospital Herne, Herne, Germany
| | - Felicitas Dammer
- Department of Vascular Surgery, University Hospital LMU Munich, Munich, Germany
| | - Theodosios Bisdas
- Department of Vascular and Endovascular Surgery, Athens Medical Center, Athens, Greece
| | - Gregory Chlouverakis
- Biostatistics Laboratory, Department of Social Medicine, School of Medicine, University of Crete, Crete, Greece
| | - Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Muenster, Germany
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17
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Li M, Wu X, Shi J, Niu Y. Endothelium dysfunction and thrombosis in COVID-19 with type 2 diabetes. Endocrine 2023; 82:15-27. [PMID: 37392341 DOI: 10.1007/s12020-023-03439-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 06/21/2023] [Indexed: 07/03/2023]
Abstract
SARS-CoV-2 can directly or indirectly damage endothelial cells. Endothelial injury, especially phosphatidylserine (PS) exposure on the outer membrane of cells, can more easily promote thrombosis. Type 2 diabetes(T2D) patients were more susceptible to COVID-19, they had more severe symptoms, higher risk of thrombotic complications, and longer duration of post-COVID-19 sequelae. This review provided a detailed overview of the mechanisms underlying endothelial dysfunction in T2D patients with COVID-19 (including long COVID), which may be influenced by hyperglycemia, hypoxia, and pro-inflammatory environments. The mechanisms of thrombosis in T2D patients with COVID-19 are also explored, particularly the effects of increased numbers of PS-exposing particles, blood cells, and endothelial cells on hypercoagulability. Given the high risk of thrombosis in T2D patients with COVID-19, early antithrombotic therapy can both minimize the impact of the disease on patients and maximize the chances of improvement, thereby alleviating patient suffering. We provided detailed guidance on antithrombotic drugs and dosages for mild, moderate, and severe patients, emphasizing that the optimal timing of thromboprophylaxis is a critical factor in influencing prognosis. Considering the potential interactions between antidiabetic, anticoagulant, and antiviral drugs, we proposed practical and comprehensive management recommendations to supplement the incomplete efficacy of vaccines in the diabetic population, reduce the incidence of post-COVID-19 sequelae, and improve patient quality of life.
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Affiliation(s)
- Mengdi Li
- Department of Endodontics, The First Hospital, Harbin Medical University, Harbin, China
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Xiaoming Wu
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
| | - Jialan Shi
- Department of Hematology, The First Hospital, Harbin Medical University, Harbin, China
- Department of Research, VA Boston Healthcare System, Harvard Medical School, Boston, MA, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Yumei Niu
- Department of Endodontics, The First Hospital, Harbin Medical University, Harbin, China.
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18
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Björck M, Boyle JR, Kolh P. In Times of Health Crisis and War, Science and Education are More Important Than Ever. Eur J Vasc Endovasc Surg 2023; 66:299-301. [PMID: 37500004 DOI: 10.1016/j.ejvs.2023.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University of Liège, Liège, Belgium; and GIGA Cardiovascular Sciences, University of Liège, Liège, Belgium
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19
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Ali A, Liang W, Abdelhafiz AS, Saleh MM, Salem H, Moazen EM, Elmazny MI, Rakha MA, Elfeky SEF. Elevation of D-dimer levels are associated with early need for mechanical ventilation support in patients with COVID-19. BMC Pulm Med 2023; 23:283. [PMID: 37537520 PMCID: PMC10401731 DOI: 10.1186/s12890-023-02551-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/05/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Severe COVID-19 disease is typically associated with an urgent need for supplemental oxygen therapy that may be successfully delivered through conventional methods or require invasive mechanical ventilation. Early prediction of the need for invasive mechanical ventilation could significantly improve outcomes of COVID-19 patients. Plasma levels of D-dimer and a number of inflammatory markers as well as values of complete blood counts, all measured in the first two days of hospital admission of COVID-19 patients, were evaluated for their significance as predictors of the eventual need for invasive mechanical ventilation support as well as their values as predictors of post-ventilation morbidly and mortality. METHODS This retrospective cohort study was conducted at a single center and included data pertaining to 200 patients with previously confirmed moderate to severe COVID-19 disease in the period between May 2021 and the end of December 2022. Data were retrieved from medical records for further analysis. RESULTS The mean (SD) age of patients stood at 59 (14) years of age, and with a majority of patients being male (77%). About 18% of cases, all of significantly older age, had been connected to invasive mechanical ventilation (IMV). Total leucocytic count (TLC), as well as levels of urea, creatinine, D-dimer, ferritin, and CRP in IMV patients were significantly higher than non-ventilated patients (p < 0.01 for all). In contrast, lymphocytic count, hemoglobin level, and platelet count were significantly lower in IMV patients (p < 0.001, 0.04, and 0.002, respectively). The mortality rate was significantly higher in IMV patients (p < 0.001). D-dimer independently predicted IMV demand (OR = 1, p = 0.001 in adjusted and unadjusted models). The utility of D-dimer was excellent; and the cutoff level of above 1415 µ/L showed sensitivity and specificity of about 92% and 76%, respectively. Also, the D-dimer level was very effective in predicting post-IMV survival; the AUC = 0.86, p = 0.02, and a cutoff value below 4558 µ/L was associated with 100% and 66% sensitivity and specificity, respectively. CONCLUSIONS High D-dimer levels independently correlated with the need for invasive mechanical ventilation. Low levels of this marker could evidently predict post-IMV survival of mechanically ventilated COVID-19 patients. Measuring D-dimer levels during routine follow up of those patients would thus be useful in predicting patient outcomes.
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Affiliation(s)
- Asmaa Ali
- Department of laboratory medicine, School of Medicine, Jiangsu University, Zhenjiang, 212013, China
- Department of pulmonary medicine, Abbassia Chest Hospital, MOH, Cairo, Egypt
- Department of respiratory allergy, Al-Rashed Allergy Centre, MOH, Kuwait, Kuwait
| | - Wu Liang
- Department of laboratory medicine, School of Medicine, Jiangsu University, Zhenjiang, 212013, China
| | - Ahmed Samir Abdelhafiz
- Department of Clinical Pathology, National Cancer Institute, Cairo University, Kasr Al-Aini Street, from El-Khalig Square, Cairo, 11796, Egypt.
| | - Mai M Saleh
- Department of chest disease, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Heba Salem
- Department of chest disease, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Eman M Moazen
- Department of chest disease, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Maram I Elmazny
- Department of anesthesia, intensive care and pain, Faculty of Medicine, Tanta University, Tanta, Egypt
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20
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Ferrer C, Cannizzaro GA, Borlizzi A, Caruso C, Giudice R. Acute ischemia of the upper and lower limbs: Tailoring the treatment to the underlying etiology. Semin Vasc Surg 2023; 36:211-223. [PMID: 37330235 DOI: 10.1053/j.semvascsurg.2023.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/13/2023] [Accepted: 04/13/2023] [Indexed: 06/19/2023]
Abstract
Acute limb ischemia (ALI) can be a devastating clinical emergency with potentially limb- or life-threatening consequences. It is defined as a quickly developing or sudden decrease in limb perfusion producing new or worsening symptoms and signs, often threatening limb viability. ALI is commonly related to an acute arterial occlusion. Rarely, extensive venous occlusion can lead to upper and lower extremities ischemia (ie, phlegmasia). The incidence of acute peripheral arterial occlusion causing ALI is approximately 1.5 cases per 10,000 people per year. The clinical presentation depends on the etiology and whether the patient has underlying peripheral artery disease. Except for traumas, the most common etiologies are embolic or thrombotic events. Peripheral embolism, likely related to embolic heart disease, is the most common cause of acute upper extremity ischemia. However, an acute thrombotic event may occur in native arteries, at the site of a pre-existing atherosclerotic plaque, or as a failure of previous vascular interventions. The presence of an aneurysm may predispose to ALI for both embolic and thrombotic mechanisms. Immediate diagnosis, accurate assessment of limb viability, and prompt intervention, when needed, play important roles in salvaging the affected limb and preventing major amputation. Severity of symptoms is usually dependent on the amount of surrounding arterial collateralization, which may often reflect a pre-existing chronic vascular disease. For this reason, early recognition of the underlying etiology is crucial for choice of best management and definitely for treatment success. Any error in the initial evaluation may negatively affect the functional prognosis of the limb and endanger the patient's life. The aim of this article was to discuss diagnosis, etiology, pathophysiology, and treatment of patients with acute ischemia of the upper and lower limbs.
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Affiliation(s)
- Ciro Ferrer
- Unit of Vascular Surgery, San Giovanni-Addolorata Hospital, Rome, Italy.
| | | | - Adelaide Borlizzi
- Unit of Vascular Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Cataldo Caruso
- Unit of Vascular Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Rocco Giudice
- Unit of Vascular Surgery, San Giovanni-Addolorata Hospital, Rome, Italy
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21
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Greistorfer T, Jud P. Clinical characteristics of COVID-19 associated vasculopathic diseases. Thromb J 2023; 21:61. [PMID: 37231476 DOI: 10.1186/s12959-023-00504-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/17/2023] [Indexed: 05/27/2023] Open
Abstract
Coronavirus disease 19 (COVID-19) has shown to be an infectious disease affecting not only of the respiratory system, but also cardiovascular system leading to different COVID-19-associated vasculopathies. Venous and arterial thromboembolic events have been frequently described among hospitalized patients with COVID-19 and inflammatory vasculopathic changes have also been observed. Several of the reported COVID-19 associated vasculopathies exhibit differences on epidemiology, clinical characteristics and outcome compared to non-COVID-19 types. This review focuses on the epidemiology, clinical, diagnostic and therapeutic characteristics as well as outcome data of COVID-19 associated thromboembolic events and inflammatory vasculopathies, elaborating similarities and differences with non-COVID-19 cohorts.
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Affiliation(s)
- Thiemo Greistorfer
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, Graz, 8036, Austria
| | - Philipp Jud
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, Graz, 8036, Austria.
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22
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Twine CP, Kakkos SK, Aboyans V, Baumgartner I, Behrendt CA, Bellmunt-Montoya S, Jilma B, Nordanstig J, Saratzis A, Reekers JA, Zlatanovic P, Antoniou GA, de Borst GJ, Bastos Gonçalves F, Chakfé N, Coscas R, Dias NV, Hinchliffe RJ, Kolh P, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Vermassen FEG, Wanhainen A, Koncar I, Fitridge R, Matsagkas M, Valgimigli M. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on Antithrombotic Therapy for Vascular Diseases. Eur J Vasc Endovasc Surg 2023; 65:627-689. [PMID: 37019274 DOI: 10.1016/j.ejvs.2023.03.042] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 04/05/2023]
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23
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Predenciuc A, Casian D, Culiuc V. Outcomes of Surgical Revascularization for Acute Limb Ischemia in COVID-19 Patients Comparing to Noninfected Cohort: A Single-Center Observational Prospective Study. Ann Vasc Surg 2023; 91:81-89. [PMID: 36549479 PMCID: PMC9762913 DOI: 10.1016/j.avsg.2022.11.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/10/2022] [Accepted: 11/23/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The purpose of the study was to compare the clinical presentation, management, and outcomes of surgical revascularization for acute limb ischemia (ALI) in 2 groups of patients-with and without SARS-CoV-2 infection. METHODS During the 2 years (01.01.2020-31.12.2021) all consecutive patients diagnosed with ALI and treated with urgent revascularization were prospectively enrolled. Based on the results of polymerase chain reaction swab for SARS-CoV-2 infection patients were allocated to group A-infected or group B-noninfected. Demographic characteristics, clinical, imaging, laboratory data, and details of treatment were collected prospectively. The composite endpoint of major amputation and/or death at 30 days after surgery was defined as main study outcome. The postoperative ankle-brachial index value, reinterventions, complications, and length of hospital stay were considered as secondary outcomes. RESULTS Overall, 130 patients (139 limbs with ALI) were analyzed-21 patients (23 limbs) in group A and 109 patients (116 limbs) in group B. The anatomical site of arterial occlusion, duration, and severity of ischemia did not differ significantly between the groups. Patients with COVID-19 had significantly shorter time from ALI onset till administration of the first dose of anticoagulant: 8 (2.5-24) hr vs. 15.7 (6-72) hr in group B, P = 0.02. Vascular imaging was performed before intervention only in 5 (23.8%) infected patients compared to 78 (71.5%) patients in group B, P < 0.001. The main outcome was registered in 38 (29.2%) patients, significantly more frequent in infected cohort: 12 (57.1%) patients in group A versus 26 (23.8%) in group B, P = 0.003. Difference was preponderantly caused by high mortality in group A-9 (42.8%) patients, compared to 17 (15.5%) patients in group B, P = 0.01. The difference in the rate of limb loss was not statistically significant: 4 (17.3%) limbs were amputated in COVID-19 patients and 12 (10.3%) limbs-in noninfected patients (P = 0.3). Combination of ALI and COVID-19 resulted in increased 30-day mortality-risk ratio (RR) 2.7 (95% confidence interval [CI]: 1.42-5.31), P = 0.002, but did not lead to significantly higher amputation rate-RR 1.6 (95% CI: 0.59-4.75), P = 0.32. In group A initial admission of the patient in the intensive care unit was an independent risk factor for amputation/death. Excepting systemic complications which were more frequently registered among COVID-19 patients: 7 (33%) cases vs. 14 (12.8%) in group B, P = 0.04; no differences in other secondary outcomes were observed between the groups. CONCLUSIONS Study demonstrates the significant negative impact of COVID-19 upon the 30-day amputation-free survival in patients undergoing urgent surgical revascularization for ALI. The difference in outcome is influenced by higher rate of mortality among infected patients, rather than by the rate of limb loss. Severity of COVID-19, namely requirement of intensive care, mostly determines the outcome of ALI treatment.
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Affiliation(s)
- Alexandru Predenciuc
- Department of General Surgery nr.3, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Vascular Surgery Clinic, Chisinau, Republic of Moldova; Division of Vascular Surgery, Institute of Emergency Medicine, Chisinau, Republic of Moldova
| | - Dumitru Casian
- Department of General Surgery nr.3, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Vascular Surgery Clinic, Chisinau, Republic of Moldova; Division of Vascular Surgery, Institute of Emergency Medicine, Chisinau, Republic of Moldova.
| | - Vasile Culiuc
- Department of General Surgery nr.3, "Nicolae Testemitanu" State University of Medicine and Pharmacy, Vascular Surgery Clinic, Chisinau, Republic of Moldova; Division of Vascular Surgery, Institute of Emergency Medicine, Chisinau, Republic of Moldova
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Earnshaw J. Bleeding Issues During Thrombolysis for Acute Leg Ischaemia. Eur J Vasc Endovasc Surg 2023; 65:405. [PMID: 36623762 DOI: 10.1016/j.ejvs.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 01/02/2023] [Indexed: 01/08/2023]
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Doelare SAN, Oukrich S, Ergin K, Jongkind V, Wiersema AM, Lely RJ, Ebben HP, Yeung KK, Hoksbergen AWJ. Major Bleeding During Thrombolytic Therapy for Acute Lower Limb Ischaemia: Value of Laboratory Tests for Clinical Decision Making, 17 Years of Experience. Eur J Vasc Endovasc Surg 2023; 65:398-404. [PMID: 36343749 DOI: 10.1016/j.ejvs.2022.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 10/17/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Regular measurement of fibrinogen as dose guidance in catheter directed thrombolysis (CDT) for acute limb ischaemia (ALI) has recently been dropped from European guidelines based on inconsistent literature. This study aimed to determine whether low fibrinogen levels and high activated partial thromboplastin time (APTT) are associated with an increased major bleeding risk during CDT. METHODS All consecutive patients treated with CDT for ALI in two Dutch hospitals between January 2004 and April 2021 were analysed retrospectively. Patients were treated with two dosing regimens (low dose: 50 000 IU/hour; high dose: 100 000 IU/hour) of urokinase and, after 2018, with a single low dose regimen of alteplase (rtPA) due to urokinase manufacturing problems. The incidence of major bleeding and associated APTT and fibrinogen levels were reviewed from patient charts. RESULTS Of the 443 included cases, 277 underwent CDT with urokinase and 166 with rtPA. The incidence of major bleeding in the whole cohort was 7%. Patients with a fibrinogen levels < 1.0 g/L developed more major bleeding than those in whom the fibrinogen level did not drop below 1.0 g/L (15% vs. 6%; p = .041). Systemic heparinisation during CDT or high (> 80 seconds) APTT were not significantly associated with major bleeding. Angiographic success (47% vs. 72%; p = .003) and 30 day amputation free survival (53% vs. 82%; p < .001) were lower for cases with major bleeding. Older age (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.02 - 1.11), cardiac history (OR 3.35, 95% CI 1.39 - 8.06), high dose regimens (≥ 75 000 IU/hour urokinase; OR 2.67, 95% CI 1.18 - 6.04), and fibrinogen values < 1.0 g/L (OR 5.59, 95% CI 1.98 - 15.77) were independent predictors for major bleeding during CDT. CONCLUSION High dose thrombolytic regimens and fibrinogen levels of ≤ 1.0 g/L are associated with more major bleeding during thrombolytic therapy. Major bleeding significantly worsened the clinical outcome. A prospective comparative study is needed to assess the benefit of monitoring fibrinogen levels.
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Affiliation(s)
- Sabrina A N Doelare
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Safae Oukrich
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Kübra Ergin
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Vincent Jongkind
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Surgery, Dijklander Hospital, Hoorn, the Netherlands
| | - Arno M Wiersema
- Department of Surgery, Dijklander Hospital, Hoorn, the Netherlands
| | - Rutger J Lely
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Radiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Harm P Ebben
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Kak K Yeung
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Arjan W J Hoksbergen
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands.
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Symptomatic Popliteal Artery Aneurysms in Recently SARS-CoV-2-Infected Patients: The Microangiopathic Thrombosis That Undermines Treatment. Diagnostics (Basel) 2023; 13:diagnostics13040647. [PMID: 36832134 PMCID: PMC9955742 DOI: 10.3390/diagnostics13040647] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/15/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Arterial and venous thrombosis are complications in SARS-CoV-2-infected patients. The microangiopathic thrombosis in affected patients can compromise results in urgent limb revascularizations. Aim of our study is to report on the incidence of symptoms development in patients affected by popliteal artery aneurysm (PAA) and to analyze the effect of COVID-19 infection on outcomes. METHODS Data on patients surgically treated for PAA from the massive widespread of COVID-19 vaccine (March 2021) to March 2022 were prospectively collected. Factors considered for analysis were: presence of symptoms, aneurysm diameter and length, time from symptom onset and hospital referral, ongoing or recently COVID-19 infection. Outcomes measures were: death, amputation, and neurological deficit. RESULTS Between March 2021 and March 2022, 35 patients were surgically treated for PAA. Among them 15 referred to our hospital for symptomatic PAA and were urgently treated. Urgent treatments included both endovascular procedures and open surgeries. Nine out of 15 symptomatic patients had an ongoing or recently recovered COVID-19 infection. COVID-19 infection was strongly associated to symptoms development in patients affected by PAA and to surgical failure in those patients (OR 40, 95% CI 2.01-794.31, p = 0.005). CONCLUSION In our series, presence of COVID-19 infection was strongly associated to ischemic symptoms onset and to complications after urgent treatment in symptomatic patients.
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Gratl A. Study Protocol of a Prospective Multicenter Observational Study Evaluating Acute Lower Limb Ischemia. J Surg Res 2023; 282:280-284. [PMID: 36347128 DOI: 10.1016/j.jss.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/21/2022] [Accepted: 09/17/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Acute lower limb ischemia (ALI) is a limb- and potentially life-threatening condition which requires urgent evaluation and treatment. Contemporary data on optimal therapy and prognosis of ALI are lacking, while surgical, hybrid, and foremost endovascular techniques have rapidly evolved over the past decades. Available clinical guidelines are not based on high-level evidence and do not fully reflect day-do-day practice. Contemporary data on etiology, procedural strategies as well as patient outcomes in ALI are urgently needed to improve care and prevent limb loss. The current study was initiated by the European Vascular Research Collaborative (EVRC), established by young European vascular specialists, and aims to provide insight into contemporary treatment strategies in ALI and its clinical results within Europe. In this manuscript we report the rationale and a detailed study protocol. MATERIAL AND METHODS The proposed study is a prospective, international, multicenter, observational study on ALI (PROMOTE-ALI) (ClinicalTrials.gov - NCT05138679). Patients with ALI (Rutherford classification grade I -III) of one or both lower extremities will be included in the study. The primary endpoint of the study is amputation-free survival (AFS) at 30 d. Secondary endpoints are freedom from target limb reintervention, freedom from complications, clinical outcome of the index leg, and limb salvage and survival at 30 and 90 d after diagnosis of ALI. CONCLUSIONS ALI remains a challenging condition and due to the heterogeneous etiology, clinical presentation and treatment strategies, a large multicenter study on this topic is needed to gain contemporary data on clinical outcomes and prognosis, especially for modern endovascular techniques. PROMOTE-ALI is expected to provide these data and set a benchmark for future randomized controlled trials (RCTs).
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Affiliation(s)
- Alexandra Gratl
- Department of Vascular Surgery, Medical University of Innsbruck, Innsbruck, Austria.
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Barie PS, Brindle ME, Khadaroo RG, Klassen TL, Huston JM. Omicron, Long-COVID, and the Safety of Elective Surgery for Adults and Children: Joint Guidance from the Therapeutics and Guidelines Committee of the Surgical Infection Society and the Surgery Strategic Clinical Network, Alberta Health Services. Surg Infect (Larchmt) 2023; 24:6-18. [PMID: 36580648 DOI: 10.1089/sur.2022.274] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: Active and recent coronavirus disease 2019 (COVID-19) infections are associated with morbidity and mortality after surgery in adults. Current recommendations suggest delaying elective surgery in survivors for four to 12 weeks, depending on initial illness severity. Recently, the predominant causes of COVID-19 are the highly transmissible/less virulent Omicron variant/subvariants. Moreover, increased survivability of primary infections has engendered the long-COVID syndrome, with protean manifestations that may persist for months. Considering the more than 600,000,000 COVID-19 survivors, surgeons will likely be consulted by recovered patients seeking elective operations. Knowledge gaps of the aftermath of Omicron infections raise questions whether extant guidance for timing of surgery still applies to adults or should apply to the pediatric population. Methods: Scoping review of relevant English-language literature. Results: Most supporting data derive from early in the pandemic when the Alpha variant of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) predominated. The Omicron variant/subvariants generally cause milder infections with less organ dysfunction; many infections are asymptomatic, especially in children. Data are scant with respect to adult surgical outcomes after Omicron infection, and especially so for pediatric surgical outcomes at any stage of the pandemic. Conclusions: Numerous knowledge gaps persist with respect to the disease, the recovered pre-operative patient, the nature of the proposed procedure, and supporting data. For example, should the waiting period for all but urgent elective surgery be extended beyond 12 weeks, e.g., after serious/critical illness, or for patients with long-COVID and organ dysfunction? Conversely, can the waiting periods for asymptomatic patients or vaccinated patients be shortened? How shall children be risk-stratified, considering the distinctiveness of pediatric COVID-19 and the paucity of data? Forthcoming guidelines will hopefully answer these questions but may require ongoing modifications based on additional new data and the epidemiology of emerging strains.
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Affiliation(s)
- Philip S Barie
- Department of Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Mary E Brindle
- Departments of Surgery and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Surgery Strategic Clinical Network, Calgary Zone, Alberta Health Services, Edmonton, Alberta, Canada
| | - Rachel G Khadaroo
- Surgery Strategic Clinical Network, Calgary Zone, Alberta Health Services, Edmonton, Alberta, Canada.,Departments of Surgery and Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Tara L Klassen
- Surgery Strategic Clinical Network, Calgary Zone, Alberta Health Services, Edmonton, Alberta, Canada.,Department of Surgery, Calgary Zone, Alberta Health Services, Edmonton, Alberta, Canada
| | - Jared M Huston
- Departments of Surgery and Science Education, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA.,Institute of Bioelectronic Medicine, The Feinstein Institute for Medical Research, Manhasset, New York, USA
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Boucher N, Dreksler H, Hooper J, Nagpal S, MirGhassemi A, Miller E. Anaesthesia for vascular emergencies - a state of the art review. Anaesthesia 2023; 78:236-246. [PMID: 36308289 DOI: 10.1111/anae.15899] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2022] [Indexed: 01/11/2023]
Abstract
In this state-of-the-art review, we discuss the presenting symptoms and management strategies for vascular emergencies. Although vascular emergencies are best treated at a vascular surgical centre, patients may present to any emergency department and may require both immediate management and safe transport to a vascular centre. We describe the surgical and anaesthetic considerations for management of aortic dissection, aortic rupture, carotid endarterectomy, acute limb ischaemia and mesenteric ischaemia. Important issues to consider in aortic dissection are extent of the dissection and surgical need for bypasses in addition to endovascular repair. From an anaesthetist's perspective, aortic dissection requires infrastructure for massive transfusion, smooth management should an endovascular procedure require conversion to an open procedure, haemodynamic manipulation during stent deployment and prevention of spinal cord ischaemia. Principles in management of aortic rupture, whether open or endovascular treatment is chosen, include immediate transfer to a vascular care centre; minimising haemodynamic changes to reduce aortic shear stress; permissive hypotension in the pre-operative period; and initiation of massive transfusion protocol. Carotid endarterectomy for carotid stenosis is managed with general or regional techniques, and anaesthetists must be prepared to manage haemodynamic, neurological and airway issues peri-operatively. Acute limb ischaemia is a result of embolism, thrombosis, dissection or trauma, and may be treated with open repair or embolectomy, under either general or local anaesthesia. Due to hypercoagulability, there may be higher numbers of acutely ischaemic limbs among patients with COVID-19, which is important to consider in the current pandemic. Mesenteric ischaemia is a rare vascular emergency, but it is challenging to diagnose and associated with high morbidity and mortality. Several peri-operative issues are common to all vascular emergencies: acute renal injury; management of transfusion; need for heparinisation and reversal; and challenging postoperative care. Finally, the important development of endovascular techniques for repair in many vascular emergencies has improved care, and the availability of transoesophageal echocardiography has improved monitoring as well as aids in surgical placement of endovascular grafts and for post-procedural evaluation.
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Affiliation(s)
- N Boucher
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - H Dreksler
- Division of Vascular Surgery, Department of Surgery, University of Ottawa, ON, Canada
| | - J Hooper
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada.,Department of Critical Care, The Ottawa Hospital, University of Ottawa, ON, Canada
| | - S Nagpal
- Division of Vascular Surgery, Department of Surgery, University of Ottawa, ON, Canada
| | - A MirGhassemi
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
| | - E Miller
- Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
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Affiliation(s)
- Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Institute of Clinical Medicine, University of Tartu, Tartu, Estonia.
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK
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31
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Muacevic A, Adler JR, Bouarhroum A. Acute Limb Ischemia in COVID-19 Patients: A Single University Center Experience. Cureus 2022; 14:e32829. [PMID: 36694504 PMCID: PMC9865446 DOI: 10.7759/cureus.32829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is currently known to lead to high rates of thrombotic complications. Of those, acute limb ischemia (ALI) was most frequently reported. Several case reports or case series had already described high mortality and amputation rates. The purpose of our study was to highlight the epidemiological, clinical, and management characteristics of coronavirus disease 2019 (COVID-19)-related ALI patients. Methods This was a monocentric, observational, and retrospective study. Records of all patients ≥18 years of age admitted with ALI and a confirmed diagnosis of COVID-19 infection between March 2020 and December 2021 were retrospectively examined. Data collected included demographics, co-morbidities, biological findings, COVID-19 pneumonia and ALI severity, anatomical location of arterial thromboembolism, treatments, and outcomes. Results During the study period, 22 patients with ALI infected with COVID-19 were evaluated. The median age was 67 years (45-88) and 18 (81.8%) were men. The main comorbidities were diabetes mellitus (36.4%), smoking (22.7%), and arterial hypertension (18.2%). All 22 patients were already diagnosed positive for SARS-CoV-2. The median duration between COVID-19 diagnosis and ALI symptom onset was six days (1-13 days). The computed tomography (CT) extent of pulmonary lesions was assessed according to the French Society of Chest Imaging. The ischemic syndrome was classified on Rutherford Stage IIA (30.4%) and IIB (43.5%). Regarding thrombotic locations, ALI had occurred essentially in the lower limbs (95% vs. 5%). A revascularization procedure was performed in 14 patients (63.6%) of the patients, and primary amputation was unavoidable in five patients (22.7%). Three patients (13.6%) did not undergo operative management, two because of their hemodynamic instability and one rejected surgery. We performed 23 revascularization procedures for 14 patients and three primary amputations. Thromboembolectomy (TE) was the technique of choice (92.8%). Below-the-knee (BTK) femoropopliteal bypass was performed in one patient. Selective tibial vessel thrombectomy was performed in four patients (28.6%). The mortality rate was 27.3%. Among survivors, two secondary amputations were needed with a limb salvage rate of 68.2%. Conclusion By the apparent end of the pandemic, our study further supports the increased risk of ALI in COVID-19-positive patients. Moreover, the results affirm the unfavorable outcomes highly impacted by rethrombosis, reinterventions, and consequently high rates of amputations and mortality.
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32
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Twine CP, Mani K. A Brief Guide to Performing Review and Meta-analysis of Rare Diseases, Procedures, and Other Low Frequency Pathology. Eur J Vasc Endovasc Surg 2022; 64:297-298. [PMID: 35934224 DOI: 10.1016/j.ejvs.2022.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 07/27/2022] [Indexed: 01/12/2023]
Affiliation(s)
| | - Kevin Mani
- Section of Vascular Surgery, Department of Surgical Sciences, Uppsala university, Uppsala, Sweden
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Coscas R, Dubosq M, Charton J, El Batti S, Gaudric J, Koskas F, Chiche L, Couture T, Davaine JM, Castier Y, Cerceau P, EL Hajjam M, Samb P, Beauchet A, Grimaldi L, Javerliat I, Goeau-Brissonniere O, Alsac JM, Onorati I, Martinod E, Desgranges P, Touma J, Cochennec F, Pellenc Q, Julia P, Coggia M. Thrombosis of Medium-Sized and Large Arteries During Covid-19 Infection: Results of the COVIVASC Study. Ann Vasc Surg 2022; 86:35-42. [PMID: 35780947 PMCID: PMC9242891 DOI: 10.1016/j.avsg.2022.04.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/15/2022] [Accepted: 04/15/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND COVID-19 infection is associated not only with venous thromboses but also with arterial thromboses (COV-ATs) in relation with an endothelial dysfunction, a coagulopathy and rhythm disorders. The incidence, the topography, and the prognosis of COV-ATs remain poorly known. The objective of this study was to report the overall experience of the Greater Paris University Hospitals (Assistance Publique - Hopitaux de Paris, AP-HP) during the first pandemic wave of COVID-19 infection. METHODS After approval by the ethics committee, a study using the AP-HP clinical data warehouse was carried out between March and May 2020. Overall, 124,609 patients had a polymerase chain reaction for COVID-19 in our hospitals, of which 25,345 were positive. From 20,710 exploitable stays, patients tested positive for COVID who presented an episode of acute COV-AT (except coronary and intracranial arteries) were selected on the basis of the French medical classification for clinical procedures codes. The data are presented as absolute values with percentages and/or means with standard deviation. RESULTS Over the studied period, 60 patients (aged 71±14 years, 42 men) presented a COV-AT at the time of their hospitalization, an incidence of 0.2%. The arterial complication occurred 3±7 days after the COVID infection and was inaugural in 30% of the cases (n = 18). The sites of COV-AT were the lower extremities (n = 35%, 58%), the abdominal aorta (n = 10%, 17%), the thoracic aorta (n = 7%, 12%), the upper limbs (n = 7%, 12%), the cerebral arteries (n = 7%, 12%), the digestive arteries (n = 6%, 10%), the renal arteries (n = 2%, 3%), and the ophthalmic artery (n = 1%, 2%). Multiple COV-ATs were observed in 13 patients (22%). At the time of diagnosis, 20 (33%) patients were in intensive care, including six (10%) patients who were intubated. On computed tomography angiography, COVID lesions were classified as moderate and severe in 25 (42%) and 21 (35%) cases, respectively. Revascularization was attempted in 27 patients (45%), by open surgery in 16 cases, using endovascular techniques in 8 cases and with a hybrid approach in three cases. Six patients (22%) required reinterventions. The duration of hospitalization was 12±9 days. Early mortality (in-hospital or at 30 days) was 30% (n = 18). Nine (15%) patients presented severe nonlethal ischemic complications. CONCLUSIONS Arterial involvement is rare during COVID-19 infection. The aorta and the arteries of the limbs are the privileged sites. The morbi-mortality of these patients is high. Future studies will have to determine if the systematization of anticoagulation therapy decreases the incidence and the severity of the condition.
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Affiliation(s)
- Raphael Coscas
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, 92104 Boulogne-Billancourt, France,UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, 94807 Villejuif, France,Correspondence to: Raphaël Coscas, Department of Vascular Surgery, Ambroise Paré University Hospital, 9 avenue Charles de Gaulle, 92104 Boulogne Cedex, France
| | - Maxime Dubosq
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, 92104 Boulogne-Billancourt, France,UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, 94807 Villejuif, France
| | - Johanna Charton
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, 92104 Boulogne-Billancourt, France,UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, 94807 Villejuif, France
| | - Salma El Batti
- Department of Cardiovascular Surgery, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Julien Gaudric
- Department of Vascular and Endovascular Surgery–Tertiary Aortic Center, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris and Sorbonne Médecine Universités, 75013 Paris, France
| | - Fabien Koskas
- Department of Vascular and Endovascular Surgery–Tertiary Aortic Center, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris and Sorbonne Médecine Universités, 75013 Paris, France
| | - Laurent Chiche
- Department of Vascular and Endovascular Surgery–Tertiary Aortic Center, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris and Sorbonne Médecine Universités, 75013 Paris, France
| | - Thibault Couture
- Department of Vascular and Endovascular Surgery–Tertiary Aortic Center, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris and Sorbonne Médecine Universités, 75013 Paris, France
| | - Jean-Michel Davaine
- Department of Vascular and Endovascular Surgery–Tertiary Aortic Center, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris and Sorbonne Médecine Universités, 75013 Paris, France
| | - Yves Castier
- Department of Vascular Surgery, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France and Paris-Diderot University, Paris, France
| | - Pierre Cerceau
- Department of Vascular Surgery, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France and Paris-Diderot University, Paris, France
| | - Mostafa EL Hajjam
- Department of Radiology, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, 92104 Boulogne-Billancourt, France
| | - Patricia Samb
- Clinical Research Unit, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France,University of Versailles Saint-Quentin en Yvelines, Paris-Saclay University, Paris, France
| | - Alain Beauchet
- Clinical Research Unit, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France,University of Versailles Saint-Quentin en Yvelines, Paris-Saclay University, Paris, France
| | - Lamiae Grimaldi
- Clinical Research Unit, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, Boulogne-Billancourt, France,University of Versailles Saint-Quentin en Yvelines, Paris-Saclay University, Paris, France
| | - Isabelle Javerliat
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, 92104 Boulogne-Billancourt, France,UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, 94807 Villejuif, France
| | - Olivier Goeau-Brissonniere
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, 92104 Boulogne-Billancourt, France,UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, 94807 Villejuif, France
| | - Jean-Marc Alsac
- Department of Cardiovascular Surgery, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Ilaria Onorati
- Department of Thoracic and Vascular Surgery, Hôpitaux Universitaires Paris Seine-Saint-Denis, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, and Université Paris 13, Sorbonne Paris Cité, UFR Santé, Médecine et Biologie Humaine, Bobigny, France
| | - Emmanuel Martinod
- Department of Thoracic and Vascular Surgery, Hôpitaux Universitaires Paris Seine-Saint-Denis, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, and Université Paris 13, Sorbonne Paris Cité, UFR Santé, Médecine et Biologie Humaine, Bobigny, France
| | - Pascal Desgranges
- Department of Vascular Surgery, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Créteil, France,Paris-Est Créteil Faculty of Medicine, Créteil, France
| | - Joseph Touma
- Department of Vascular Surgery, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Créteil, France,Paris-Est Créteil Faculty of Medicine, Créteil, France
| | - Frédéric Cochennec
- Department of Vascular Surgery, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Créteil, France,Paris-Est Créteil Faculty of Medicine, Créteil, France
| | - Quentin Pellenc
- Department of Vascular Surgery, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France and Paris-Diderot University, Paris, France
| | - Pierre Julia
- Department of Cardiovascular Surgery, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 75015 Paris, France
| | - Marc Coggia
- Department of Vascular Surgery, Ambroise Paré University Hospital, Assistance Publique-Hôpitaux de Paris, 92104 Boulogne-Billancourt, France,UMR 1018, Inserm-Paris11 - CESP, Versailles Saint-Quentin-en-Yvelines University, Paris-Saclay University, Paul Brousse Hospital, 94807 Villejuif, France
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Bjorck M. Author response to: Comment on: Collaborative research: population-based data and validation are necessary. Br J Surg 2022; 109:e113. [PMID: 35762940 PMCID: PMC10364774 DOI: 10.1093/bjs/znac209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/24/2022] [Indexed: 11/14/2022]
Affiliation(s)
- Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala, Sweden
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Björck M. Collaborative research: population-based data and validation are necessary. Br J Surg 2022; 109:578-579. [PMID: 35416953 PMCID: PMC10364721 DOI: 10.1093/bjs/znac100] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 03/01/2022] [Accepted: 03/15/2022] [Indexed: 08/02/2023]
Affiliation(s)
- Martin Björck
- Correspondence to: Martin Björck, Department of Surgical Sciences, Uppsala University, SE-75185 Uppsala, Sweden (e-mail: )
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Editor's Choice - European Society for Vascular Surgery Clinical Practice Guideline Development Scheme: An Overview of Evidence Quality Assessment Methods, Evidence to Decision Frameworks, and Reporting Standards in Guideline Development. Eur J Vasc Endovasc Surg 2022; 63:791-799. [PMID: 35697645 DOI: 10.1016/j.ejvs.2022.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/17/2022] [Indexed: 01/12/2023]
Abstract
OBJECTIVE A structured and transparent approach is instrumental in translating research evidence to health recommendations and evidence informed clinical decisions. The aim was to conduct an overview and analysis of principles and methodologies for health guideline development. METHODS A literature review on methodologies, strategies, and fundamental steps in the process of guideline development was performed. The clinical practice guideline development process and methodology adopted by the European Society for Vascular Surgery are also presented. RESULTS Sophisticated methodologies for health guideline development are being applied increasingly by national and international organisations. Their overarching principle is a systematic, structured, transparent, and iterative process that is aimed at making well informed healthcare choices. Critical steps in guideline development include the assessment of the certainty of the body of evidence; evidence to decision frameworks; and guideline reporting. The goal of strength of evidence assessments is to provide well reasoned judgements about the guideline developers' confidence in study findings, and several evidence hierarchy schemes and evidence rating systems have been described for this purpose. Evidence to decision frameworks help guideline developers and users conceptualise and interpret the construct of the quality of the body of evidence. The most widely used evidence to decision frameworks are those developed by the GRADE Working Group and the WHO-INTEGRATE, and are structured into three distinct components: background; assessment; and conclusions. Health guideline reporting tools are employed to ensure methodological rigour and transparency in guideline development. Such reporting instruments include the AGREE II and RIGHT, with the former being used for guideline development and appraisal, as well as reporting. CONCLUSION This guide will help guideline developers/expert panels enhance their methodology, and patients/clinicians/policymakers interpret guideline recommendations and put them in context. This document may be a useful methodological summary for health guideline development by other societies and organisations.
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Bunch CM, Moore EE, Moore HB, Neal MD, Thomas AV, Zackariya N, Zhao J, Zackariya S, Brenner TJ, Berquist M, Buckner H, Wiarda G, Fulkerson D, Huff W, Kwaan HC, Lankowicz G, Laubscher GJ, Lourens PJ, Pretorius E, Kotze MJ, Moolla MS, Sithole S, Maponga TG, Kell DB, Fox MD, Gillespie L, Khan RZ, Mamczak CN, March R, Macias R, Bull BS, Walsh MM. Immuno-Thrombotic Complications of COVID-19: Implications for Timing of Surgery and Anticoagulation. Front Surg 2022; 9:889999. [PMID: 35599794 PMCID: PMC9119324 DOI: 10.3389/fsurg.2022.889999] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/05/2022] [Indexed: 12/12/2022] Open
Abstract
Early in the coronavirus disease 2019 (COVID-19) pandemic, global governing bodies prioritized transmissibility-based precautions and hospital capacity as the foundation for delay of elective procedures. As elective surgical volumes increased, convalescent COVID-19 patients faced increased postoperative morbidity and mortality and clinicians had limited evidence for stratifying individual risk in this population. Clear evidence now demonstrates that those recovering from COVID-19 have increased postoperative morbidity and mortality. These data-in conjunction with the recent American Society of Anesthesiologists guidelines-offer the evidence necessary to expand the early pandemic guidelines and guide the surgeon's preoperative risk assessment. Here, we argue elective surgeries should still be delayed on a personalized basis to maximize postoperative outcomes. We outline a framework for stratifying the individual COVID-19 patient's fitness for surgery based on the symptoms and severity of acute or convalescent COVID-19 illness, coagulopathy assessment, and acuity of the surgical procedure. Although the most common manifestation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is COVID-19 pneumonitis, every system in the body is potentially afflicted by an endotheliitis. This endothelial derangement most often manifests as a hypercoagulable state on admission with associated occult and symptomatic venous and arterial thromboembolisms. The delicate balance between hyper and hypocoagulable states is defined by the local immune-thrombotic crosstalk that results commonly in a hemostatic derangement known as fibrinolytic shutdown. In tandem, the hemostatic derangements that occur during acute COVID-19 infection affect not only the timing of surgical procedures, but also the incidence of postoperative hemostatic complications related to COVID-19-associated coagulopathy (CAC). Traditional methods of thromboprophylaxis and treatment of thromboses after surgery require a tailored approach guided by an understanding of the pathophysiologic underpinnings of the COVID-19 patient. Likewise, a prolonged period of risk for developing hemostatic complications following hospitalization due to COVID-19 has resulted in guidelines from differing societies that recommend varying periods of delay following SARS-CoV-2 infection. In conclusion, we propose the perioperative, personalized assessment of COVID-19 patients' CAC using viscoelastic hemostatic assays and fluorescent microclot analysis.
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Affiliation(s)
- Connor M. Bunch
- Department of Emergency Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Ernest E. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, United States
| | - Hunter B. Moore
- Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, United States
| | - Matthew D. Neal
- Pittsburgh Trauma Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Anthony V. Thomas
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
| | - Nuha Zackariya
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
| | - Jonathan Zhao
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Sufyan Zackariya
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Toby J. Brenner
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Margaret Berquist
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Hallie Buckner
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Grant Wiarda
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Daniel Fulkerson
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
- Department of Neurosurgery, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Wei Huff
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
- Department of Neurosurgery, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Hau C. Kwaan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Genevieve Lankowicz
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | | | | | - Etheresia Pretorius
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Maritha J. Kotze
- Division of Chemical Pathology, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University and National Health Laboratory Service, Tygerberg Hospital, Cape Town, South Africa
| | - Muhammad S. Moolla
- Division of General Medicine, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Sithembiso Sithole
- Division of General Medicine, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Tongai G. Maponga
- Division of Medical Virology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Douglas B. Kell
- Department of Physiological Sciences, Stellenbosch University, Stellenbosch, South Africa
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular and Integrative Biology, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
- The Novo Nordisk Foundation Centre for Biosustainability, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - Mark D. Fox
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
| | - Laura Gillespie
- Department of Quality Assurance and Performance Improvement, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Rashid Z. Khan
- Department of Hematology, Michiana Hematology Oncology, Mishawaka, IN, United States
| | - Christiaan N. Mamczak
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
- Department of Orthopaedic Trauma, Memorial Hospital South Bend, South Bend, IN, United States
| | - Robert March
- Department of Cardiothoracic Surgery, St. Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Rachel Macias
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
- Department of Plastic and Reconstructive Surgery, St. Joseph Regional Medical Center, Mishawaka, IN, United States
| | - Brian S. Bull
- Department of Pathology and Human Anatomy, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Mark M. Walsh
- Indiana University School of Medicine South Bend Campus, Notre Dame, IN, United States
- Department of Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, United States
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Clinical and economic impact of COVID in Vascular Surgery at a Tertiary University 'Hub' Hospital of Italy. Ann Vasc Surg 2022; 83:97-107. [PMID: 35247541 PMCID: PMC8889731 DOI: 10.1016/j.avsg.2022.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 11/22/2022]
Abstract
Background Since the first cases of a novel respiratory disease were reported in December 2019, coronavirus disease (COVID-19) Emergency State (Cov-ES) caused a worldwide outbreak requiring a complete reorganization of the healthcare system and new management of its personnel; aim of this study was to analyze the clinical and financial impact of Cov-ES in the Department of Vascular Surgery at a Tertiary University “Hub” Hospital in northeast Italy. Methods Differences in clinical practice according to Diagnostic Related Group (DRG) and International Statistical Classification of Diseases (ICD) and Related Health Problems and the financial impact of Cov-ES were considered. Vascular procedures performed between March 2019 and December 2019 (Prepandemic) were compared to those performed in the period March–December 2020 (Pandemic). Prepandemic and pandemic reimbursements of all vascular activities and the top 3 vascular diagnoses were evaluated. Results Prepandemic versus pandemic era documented a decrease of vascular consultations performed (2,882 vs. 2,270, −21.2%). The number of total vascular procedures decreased from 997 to 797 (−20.1%) with a higher reduction observed in outpatient surgical activities (247 to 136, −45.0%, P = 0.0005) rather than inpatient surgical activities (750 vs. 661, 11.9%, P = 0.02). Length of hospital stay (LOS) increased from 3.3 ± 2.7 days in prepandemic to 5.3 ± 3.9 in the pandemic era (P = 0.004). Among patients with limb-threatening ischemia, the rate of major limb amputation was higher in the pandemic (3.3% vs. 5.4%, respectively, P = 0.02), and a higher rate of elective hospitalization procedures was performed as urgent/emerging setting after clinical deterioration (2.8 % vs. 6.4%, P = 0.0002). According to DRG classification, an increase of “complicated” limb-threatening ischemia (DRG 554) and aortic aneurysm (DRG 110) was observed prepandemic to pandemic (+84.2% and +25.0%, respectively). Total reimbursement for vascular activities between pandemic versus prepandemic was 4,646,108€ vs. 5,054,398€, respectively (−8.0%). Management of “complicated” limb-threatening ischemia (DRG 554) and aortic aneurysm (DRG 110) required a higher clinical and financial support that was translated into higher economic reimbursement during the pandemic (273,035€ vs. 150,005€, +82.0% and 749,250€ vs. 603,680€, +24.1%, respectively). Conclusions During the pandemic, the main resources were employed for the treatment of limb-threatening ischemia, aortic aneurysm, and carotid stenosis. Inpatient activities documented an increase in major limb amputation and LOS. An increased reimbursement for each vascular procedure and for all “complicated” diagnoses revealed that the more serious and resource-demanding pathology occurred in this period.
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Achim A, Kákonyi K, Jambrik Z, Ruzsa Z. A case report of COVID-19-associated acute hand ischaemia in a young professional volleyball player. Eur Heart J Case Rep 2022; 6:ytac099. [PMID: 35345423 PMCID: PMC8941628 DOI: 10.1093/ehjcr/ytac099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/06/2021] [Accepted: 02/21/2022] [Indexed: 12/31/2022]
Abstract
Background Several coronavirus disease-19 (COVID-19)-associated complications are being
increasingly reported, including arterial and venous thrombo-embolic events
that may lead to amputation of the affected limbs. So far, acute upper limb
ischaemia (ULI) has been reported only in critically ill patients. Case summary Herein, we aimed to present a case of a 29-year-old, otherwise healthy male
volleyball player, with acute ischaemic signs in the upper extremity who was
diagnosed with COVID-19 1 month before the ischaemic event. It has
been shown that volleyball players experience repetitive stress that
involves their hands and, in particular, their fingers. Repetitive trauma
can lead to local vascular abnormalities, such as reduced capillarization
and lower resting blood flow that can lead to pain and cold digits, but
never acute ULI. Discussion To our knowledge, this is the first case of such a hypercoagulable
synergistic mechanism that leads to a high thrombus burden. Intra-arterial
local thrombolysis and percutaneous transluminal angioplasty failed to
succeed, and percutaneous large-bore embolectomy with the Indigo Aspiration
System (Penumbra Inc., CA, USA) was deemed necessary.
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Affiliation(s)
- Alexandru Achim
- Invasive Cardiology Division, Internal Medicine Department, Faculty of Medicine, University of Szeged, Semmelweis Str 6, 6726, Szeged, Hungary.,Niculae Stancioiu Heart Institute, University of Medicine and Pharmacy "Iuliu Hatieganu", Cluj-Napoca, Romania
| | - Kornél Kákonyi
- Invasive Cardiology Division, Internal Medicine Department, Faculty of Medicine, University of Szeged, Semmelweis Str 6, 6726, Szeged, Hungary
| | - Zoltán Jambrik
- Invasive Cardiology Division, Internal Medicine Department, Faculty of Medicine, University of Szeged, Semmelweis Str 6, 6726, Szeged, Hungary
| | - Zoltán Ruzsa
- Invasive Cardiology Division, Internal Medicine Department, Faculty of Medicine, University of Szeged, Semmelweis Str 6, 6726, Szeged, Hungary
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Exelmans W, Knaapen L, Boonman-de Winter L, Vriens P, van der Laan L. Treating peripheral arterial occlusive disease and acute limb ischemia during a COVID-19 pandemic in 2020. Ann Vasc Surg 2022; 84:1-5. [PMID: 35108551 PMCID: PMC8801262 DOI: 10.1016/j.avsg.2022.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/05/2022] [Indexed: 11/29/2022]
Abstract
Background For many surgeons the outbreak of SARS-CoV-2 meant a downscaling of surgical interventions. The aim of this study was to investigate the impact of the measures taken on the care for patients with peripheral arterial disease (PAOD) and acute limb ischemia (ALI). Methods A retrospective analysis of the vascular practices of 2 major teaching hospitals in the Netherlands was performed. All interventions and outpatient visits for PAOD or ALI in 2020 were included. Patients treated in 2018 and 2019 were to serve as a control group. Data were analysed using descriptive statistics. Results In 2020, a total of 1513 procedures were performed for PAOD or ALI. This did not differ significantly from previous years. Overall, Fontaine 2 and 4 were the most frequent indications for intervention. A significant increase in the number of major amputations was observed in 2020 compared to 2018 (P< 0.01). This was mainly due to patients suffering from PAOD Fontaine 4. Inversely, a reduction in the number of femoro-popliteal bypasses was observed between 2020 and 2018. The number of outpatient visit due to Fontaine 2 was significantly lower in 2020 compared to 2018. Conclusions The vascular practices of our hospitals were minimally influenced by the measures taken due to the outbreak of SARS-CoV-2. There was an increase in the number of amputation but an enormous surge in patients presenting with critical limb ischemia was not observed.
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Affiliation(s)
- W Exelmans
- Department of Surgery, Amphia Hospital, Breda, The Netherlands.
| | - L Knaapen
- Department of Surgery, Elisabeth-Twee Steden Hospital, Tilburg, The Netherlands
| | - Ljm Boonman-de Winter
- Department of Science and Statistics, Amphia Hospital, Breda, The Netherlands; Management Board, Admiraal de Ruyter Hospital, Goes, The Netherlands
| | - Pwhe Vriens
- Department of Surgery, Elisabeth-Twee Steden Hospital, Tilburg, The Netherlands
| | - L van der Laan
- Department of Surgery, Amphia Hospital, Breda, The Netherlands; Department of Cardiovascular science, University of Leuven, Leuven, Belgium
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Kulezic A, Acosta S. Epidemiology and Prognostic Factors in Acute Lower Limb Ischaemia: A Population Based Study. Eur J Vasc Endovasc Surg 2022; 63:296-303. [PMID: 35027271 DOI: 10.1016/j.ejvs.2021.10.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/28/2021] [Accepted: 10/15/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the contemporary population based incidence of acute lower limb ischaemia (ALI) and factors associated with major amputation/death at one year. METHODS In this retrospective observational study, in hospital, operation, radiological, and autopsy registries were scrutinised to capture 161 citizens of Malmö, Sweden, with ALI between 2015 and 2018. Age and sex specific incidence rates were calculated in the population of Malmö between 2015 and 2018, expressed as number of patients per 100 000 person years (PY). Independent risk factors for major amputation/death at one year were identified by multivariable logistic regression analysis and expressed as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS One hundred and sixty-one patients with ALI gave an overall incidence of 12.2/100 000 PY (95% CI 10.3 - 14.1), with no sex related differences. Embolism (42.2%) was the most common cause of ALI. Among 52 patients with atrial fibrillation, 38.5% were on anticoagulant medication. Endovascular or open vascular revascularisation was performed in 54.7% of patients. The total cause specific mortality ratio was 2.63 (95% CI 1.66 - 3.61)/1 000 deaths, without no sex related differences. The combined major amputation/mortality rate at one year for the whole cohort was 46.6%. Rutherford ≥ IIb ALI (OR 4.19, 95% CI 1.94 - 9.02; p < .001), age (OR 1.03/year, 95% CI 1.00 - 1.06; p = .036), female sex (OR 2.37, 95% 1.07 - 5.26; p = .034), and anaemia (OR 2.46, 95% CI 1.08 - 5.62; p = .033) were associated with an increased risk of major amputation/death at one year. The major amputation/mortality rate at one year was 100% (n = 14/14) for patients living in a nursing home on admission. CONCLUSION The incidence of ALI appears to be unchanged, and major amputation and mortality at one year remain high. It is necessary to include the substantial proportion of patients with ALI that do not undergo revascularisation in epidemiological studies. There is room for improvement in anticoagulation therapy in patients with atrial fibrillation to prevent ALI due to embolism. Research on gender inequalities in patients with ALI is warranted.
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Affiliation(s)
- Andrea Kulezic
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.
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Whitman B, Earnshaw J. Acute Leg Ischaemia: Call to Arms. Eur J Vasc Endovasc Surg 2022; 63:304. [PMID: 35027276 DOI: 10.1016/j.ejvs.2021.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 11/30/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Birgit Whitman
- Research Governance & Integrity University of Birmingham, Birmingham, UK
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Acute Limb Ischaemia in the COVID-19 Era: a Clinical and Organisational Challenge. Eur J Vasc Endovasc Surg 2022; 63:90. [PMID: 34686455 PMCID: PMC8426287 DOI: 10.1016/j.ejvs.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 01/04/2023]
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Abstract
BACKGROUND Acute limb ischaemia usually is caused by a blood clot blocking an artery or a bypass graft. Severe acute ischaemia will lead to irreversible damage to muscles and nerves if blood flow is not restored in a few hours. Once irreversible damage occurs, amputation will be necessary and the condition can be life-threatening. Infusion of clot-busting drugs (thrombolysis) is a useful tool in the management of acute limb ischaemia. Fibrinolytic drugs are used to disperse blood clots (thrombi) to clear arterial occlusion and restore blood flow. Thrombolysis is less invasive than surgery. A variety of techniques are used to deliver fibrinolytic agents. This is an update of a review first published in 2004. OBJECTIVES To compare the effects of infusion techniques during peripheral arterial thrombolysis for treatment of patients with acute limb ischaemia. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registries to 20 October 2020. We undertook reference checking to identify additional studies. SELECTION CRITERIA We included all randomised controlled trials (RCTs) comparing infusion techniques for fibrinolytic agents in the treatment of acute limb ischaemia. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as recommended by Cochrane. We assessed the risk of bias in included trials using the Cochrane 'Risk of bias' tool. We evaluated certainty of evidence using GRADE. For dichotomous outcomes, we calculated the odds ratio (OR) with the corresponding 95% confidence interval (CI). We were not able to carry out meta-analyses due to clinical heterogeneity, so we have reported the results and performed the comparisons narratively. The main outcomes of interest were amputation-free survival or limb salvage, amputation, mortality, vessel patency, duration of thrombolysis, and complications such as cerebrovascular accident and major and minor bleeding. MAIN RESULTS Nine studies with a total of 671 participants are included in this update. Trials covered a variety of infusion techniques, dosage regimens, and adjunctive agents. We grouped trials according to types of techniques assessed (e.g. intravenous and intra-arterial delivery of the agent, 'high-' and 'low-dose' regimens of the agent, continuous infusion and 'forced infusion' of the agent, use of adjunctive antiplatelet agents). We assessed the certainty of evidence as very low to low due to the limited power of individual studies to deliver clinically relevant results, small and heterogeneous study populations, use of different inclusion criteria by each study in terms of severity and duration of ischaemia, considerably different outcome measures between trials, and use of different fibrinolytic agents. This heterogeneity prevented pooling of data in meta-analyses. No regimen has been shown to confer benefit in terms of amputation-free survival (at 30 days), amputation, or death. For vessel patency, complete success was more likely with intra-arterial (IA) than with intravenous (IV) infusion (odds ratio (OR) 13.22, 95% confidence interval (CI) 2.79 to 62.67; 1 study, 40 participants; low-certainty evidence); radiological failure may be more likely with IV infusion (OR 0.02, 95% CI 0.00 to 0.38; 1 study, 40 participants; low-certainty evidence). Due to the small numbers involved in each arm and design differences between arms, it is not possible to conclude whether any technique offered any advantage over another. None of the treatment strategies clearly affected complications such as cerebrovascular accident or major bleeding requiring surgery or blood transfusion. Minor bleeding complications were more frequent in systemic (intravenous) therapy compared to intra-arterial infusion (OR 0.03, 95% CI 0.00 to 0.56; 1 study, 40 participants), and in high-dose compared to low-dose therapy (OR 0.11, 95% CI 0.01 to 0.96; 1 study, 63 participants). Limited evidence from individual trials appears to indicate that high-dose and forced-infusion regimens reduce the duration of thrombolysis. In one trial, the median duration of infusion was 4 hours (range 0.25 to 46) for the high-dose group and 20 hours (range 2 to 46) for the low-dose group. In a second trial, treatment using pulse spray was continued for a median of 120 minutes (range 40 to 310) compared with low-dose infusion for a median of 25 hours (range 2 to 60). In a third trial, the median duration of therapy was reduced with pulse spray at 195 minutes (range 90 to 1260 minutes) compared to continuous infusion at 1390 minutes (range 300 to 2400 minutes). However, none of the studies individually showed improvement in limb salvage at 30 days nor benefit for the amputation rate related to the technique of drug delivery. Similarly, no studies reported a clear difference in occurrence of cerebrovascular accident or major bleeding. Although 'high-dose' and 'forced-infusion' techniques achieved vessel patency in less time than 'low-dose' infusion, more minor bleeding complications may be associated (OR 0.11, 95% CI 0.01 to 0.96; 1 study, 72 participants; and OR 0.48, 95% CI 0.17 to 1.32; 1 study, 121 participants, respectively). Use of adjunctive platelet glycoprotein IIb/IIIa antagonists did not improve outcomes, and results were limited by inclusion of participants with non-limb-threatening ischaemia. AUTHORS' CONCLUSIONS There is insufficient evidence to show that any thrombolytic regimen provides a benefit over any other in terms of amputation-free survival, amputation, or 30-day mortality. The rate of CVA or major bleeding requiring surgery or blood transfusion did not clearly differ between regimens but may occur more frequently in high dose and IV regimens. This evidence was limited and of very low certainty. Minor bleeding may be more common with high-dose and IV regimens. In this context, thrombolysis may be an acceptable therapy for patients with marginally threatened limbs (Rutherford grade IIa) compared with surgery. Caution is advised for patients who do not have limb-threatening ischaemia (Rutherford grade I) because of risks of major haemorrhage, cerebrovascular accident, and death from thrombolysis.
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Affiliation(s)
| | - Jai V Patel
- Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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An Observational Study on Patients with Acute Limb Ischemia and SARS-CoV-2 Infection: Early and Late Results in Limb Salvage Rate. J Clin Med 2021; 10:jcm10215083. [PMID: 34768611 PMCID: PMC8584433 DOI: 10.3390/jcm10215083] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 01/08/2023] Open
Abstract
An observational study on 22 patients presenting with acute limb ischemia and SARS-CoV-2 infection, and without any other embolic risk factors, was performed. All patients were classified according to Rutherford classification for acute limb ischemia. The primary goal of this study was to assess the risk of amputation in these patients after revascularization procedures. The secondary goal was to find the correlation between acute limb ischemia (ALI) severity, patient comorbidities, risk of death, and the association of SARS-CoV-2 infection. The patients were treated by open surgery (18 patients—81.81%) or by the means of endovascular techniques (four patients—18.18%). The amputation-free survival rate was 81.81% in hospital and 86.36% at 1-month follow-up. In this study, the presence of SARS-CoV-2 infection did not influence the amputation-free survival rate: it was only the risk factor for the arterial thrombosis and the trigger for the acute ischemic event. The application of the standard treatment—open surgery or endovascular revascularization—in patients with acute limb ischemia and SARS-CoV-2 infection represents the key to success for lower limb salvage.
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