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Chaney M, Joshi G, Serrato JC, Rashid M, Jacobs A, Jacobs CE, White JV, Schwartz LB, El Khoury R. Morbidity and mortality of common femoral endarterectomy. J Vasc Surg 2024; 80:199-203. [PMID: 38360191 DOI: 10.1016/j.jvs.2024.01.211] [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: 12/19/2023] [Revised: 01/21/2024] [Accepted: 01/28/2024] [Indexed: 02/17/2024]
Abstract
OBJECTIVE Common femoral endarterectomy (CFE) comprises the current standard-of-care for symptomatic common femoral artery occlusive disease. Although it provides effective inflow revascularization via a single incision, it remains an invasive procedure in an often-frail patient population. The purpose of this retrospective clinical study was to assess the morbidity and mortality of CFE in a contemporary cohort. METHODS Consecutive CFEs performed at a large, urban hospital were reviewed. Six-month mortality, local complications (hematoma, lymphatic leak, pseudoaneurysm, wound infection, and/or dehiscence), and systemic complications were analyzed using univariate and multivariate analyses. RESULTS A total of 129 isolated CFEs were performed over 7 years for claudication (36%), rest pain (16%), tissue loss (29%), or acute on chronic limb ischemia (21%). Mean age was 75 ± 9 years, and 68% of patients were male. Comorbidities were prevalent, including coronary artery disease (54%), diabetes (41%), chronic pulmonary disease (25%), and congestive heart failure (22%). The majority of CFEs were performed under general anesthesia (98%) with patch angioplasty using bovine pericardium (73% vs 27% Dacron). Twenty-two patients (17%) sustained local complications following the procedure; their occurrence was significantly associated with obesity (P = .002) but no technical or operative factors. Nineteen patients (15%) sustained serious systemic complications; their occurrence was significantly associated with chronic limb-threatening ischemia (P < .001), and a high American Society of Anesthesiologists (ASA) class (P = .002). By 6 months, 17 patients (13%) had died. Being on dialysis, presenting with chronic limb-threatening ischemia, and being in a high ASA class at the time of operation were all associated with 6-month mortality; a high ASA class at the time of operation was independently predictive of mortality (odds ratio, 3.08; 95% confidence interval, 1.03-9.24; P = .044). CONCLUSIONS Although commonly performed, CFE is not a benign vascular procedure. Disease presentation, anesthetic risk, and expected longevity play an important role in clinical outcomes. Evolving endovascular approaches to the common femoral artery could serve to reduce morbidity and mortality in the future.
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Affiliation(s)
- Michael Chaney
- Homer Stryker School of Medicine, Western Michigan University, Kalamazoo, MI
| | - Gaurang Joshi
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | | | - Mohammad Rashid
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Abraham Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Chad E Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Rym El Khoury
- Department of Surgery, Division of Vascular Surgery, NorthShore University Health Systems, Evanston, IL.
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Scheidhauer H, Moebius-Winkler S, Aftanski P, Schulze PC, Kretzschmar D. Analysis of interventional treatment options of the common femoral artery - a retrospective single center experience. VASA 2024; 53:227-236. [PMID: 38738466 DOI: 10.1024/0301-1526/a001125] [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] [Indexed: 05/14/2024]
Abstract
Background: Due to the rapid development of treatment techniques of peripheral arterial disease (PAD) treatment is nowadays predominantly interventional. An exception are lesions of the common femoral artery (CFA), which should be treated surgically according to vascular guidelines. However, recent evidence has shown that endovascular techniques, e.g. stenting, have comparable clinical outcomes while causing fewer complications. The aim of the present analysis was to evaluate the therapeutic success of endovascular therapy of CFA lesions in a single center, all - comers registry. Patients and methods: All patients who were treated for a CFA lesion at the Department of Internal Medicine I of the University Hospital Jena in the period from 01/2017 to 12/2020 were included. Treatment success was determined by evaluating the ankle-brachial-index (ABI) pre- and post-interventional as well as after follow-up (FU), measuring walking distance (WD) and by target revascularization rate (TLR) and primary patency rate (PPR). Results: The analysis included 109 patients with a mean age of 73.4 years, with 67% (73) of those being men. 72 patients received interventional treatment, whereas 33 were treated surgically and 4 conservatively. Resting ABI in the overall cohort showed an increase from 0.5 to 0.7 post intervention (p=<0.05; mean FU-time: 6.5 months). In the interventional cohort ABI increases from 0.6 to 0.8 (p=<0.05; mean FU-time: 5,8 months) at FU and from 0.3 to 0.6 (p=<0.05; mean FU-time: 8,8 month) in the surgically treated group. The WD improved in the whole collective from 116.5 meter (m) to 152.5 m (p=<0.05). The TLR showed no significant difference with 8.1% after interventional treatment and 6.1% after vascular surgery in the present analysis (p=0.72) as well as PPR with 89.8% after EVT and 90.9% after surgical approach (p=0.87). The intra-/postinterventional complication rate was 5.5% in the intervention group, compared to postoperative complication rate of 15.2% in the surgically treated group. Conclusions: The present analysis demonstrates that even in a real-world, all-comers collective, interventional therapy for CFA lesions was safe and equally effective as the surgically treated patient cohort. Continuing to generate registry data is important to eventually initiate a paradigm shift.
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Affiliation(s)
- Hendrik Scheidhauer
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller-University Jena, Germany
| | - Sven Moebius-Winkler
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller-University Jena, Germany
| | - Pawel Aftanski
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller-University Jena, Germany
| | - P Christian Schulze
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller-University Jena, Germany
| | - Daniel Kretzschmar
- Department of Internal Medicine I, Jena University Hospital, Friedrich-Schiller-University Jena, Germany
- HUGG-Heart- and vascular medicine Goslar, Goslar, Germany
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Rastan A, Böhme T, Zeller T. Percutaneous intervention versus surgery in the treatment of common femoral artery lesions: study protocol for the prospective, multi-center, randomized PESTO-CFA trial. Trials 2024; 25:370. [PMID: 38851710 PMCID: PMC11162007 DOI: 10.1186/s13063-024-08219-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 06/03/2024] [Indexed: 06/10/2024] Open
Abstract
BACKGROUND Endovascular therapy has become established as a first-line therapy in most arterial regions. However, open vascular surgery (endarterectomy) remains the treatment of choice for common femoral artery (CFA) lesions. The aim of this study is to investigate the acute and mid-term results of directional atherectomy plus drug-coated balloon (DCB) in comparison to endarterectomy in treatment of de novo arteriosclerotic CFA lesions. METHODS This prospective, randomized, multicenter non-inferiority study will enroll 306 participants with symptomatic (Rutherford category 1 to 5) de novo stenosis of the CFA including the bifurcation. Patients eligible for both treatment groups could be included in this 1:1 randomized trial. Primary efficacy endpoint is patency of the target lesion at 12 months defined as restenosis < 50% without the need of clinically driven target lesion revascularization (cdTLR). Primary safety endpoint is a combined endpoint including death, myocardial infarction, major or minor amputation of the target limb, and peri-procedural complications at 30 days. Secondary endpoints include primary patency of the target lesion at 6 and 24 months, secondary patency, cdTLR 6, 12, and 24 months, change in ankle-brachial index, and Rutherford-Becker class at 6, 12, and 24 months. Limb salvage, change in quality of life measured by Walking Impairment Questionnaire, and major adverse events including death, myocardial infarction, and minor or major amputation of the target limb will be determined at 6, 12, 24, and 36 months. DISCUSSION Endovascular treatment of CFA lesions is still a matter of debate. Few studies compared modern endovascular therapy methods against the so-called gold standard surgical endarterectomy so far. Based on recent positive results, this study aims to confirm non-inferiority of a "leaving nothing behind" endovascular approach combining directional atherectomy and DCB compared to surgical therapy. TRIAL REGISTRATION ClinicalTrials.gov NCT02517827.
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Affiliation(s)
- Aljoscha Rastan
- Department of Angiology, Cantonal Hospital Lucerne, Lucerne, Switzerland.
| | - Tanja Böhme
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Thomas Zeller
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg, Germany
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Chaney M, Joshi G, Cataneo Serrato JL, Rashid M, Jacobs A, Jacobs CE, White JV, Schwartz LB, El Khoury R. The natural history of isolated common femoral endarterectomy for chronic limb-threatening ischemia. J Vasc Surg 2024:S0741-5214(24)01229-1. [PMID: 38823529 DOI: 10.1016/j.jvs.2024.05.050] [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: 01/29/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE Occlusive disease of the common femoral artery can generate profound lower extremity ischemia as the normal collateral pathways from the profunda to the superficial femoral artery cannot adequately develop. In patients with lifestyle-limiting claudication, isolated common femoral endarterectomy (CFE) is highly effective. Because CFE does not provide direct, in-line flow to the plantar arch, it has been felt to provide inadequate revascularization to patients with chronic limb-threatening ischemia (CLTI). The purpose of this retrospective clinical study was to report and assess the natural history of selected patients with CLTI treated with isolated CFE (without concomitant infrainguinal revascularization). METHODS Consecutive CFEs performed in a large, urban hospital for CLTI between 2014 and 2021 were reviewed. Patient characteristics, limb, and anatomical stages using the Wound, Ischemia, foot Infection (WIfI) and Global Limb Anatomic Staging System were tabulated. Limb-specific and survival-related end points were analyzed. RESULTS Fifty-eight patients presenting with CLTI underwent isolated CFE (mean age, 74 ± 10 years; 62% male, 90% current or prior smoker). Comorbidities included diabetes (52%), coronary artery disease (55%), congestive heart failure (22%), and end-stage renal failure on hemodialysis (5%). Patients presented with either rest pain (36%) or tissue loss (64%); the latter group exhibited advanced limb threat (68% in WIfI stage 3 or 4). The majority of patients had associated severe infrainguinal disease (50% Global Limb Anatomic Staging Systems 3). After a median follow-up of 17 months (range, 10-29 months), vascular reintervention was required in 7 patients (12%). One patient (2%) required major limb amputation after presentation in WIfI stage 4 (W3I3fI0). Indeed, WIfI stage 4 was a significant univariate predictor of the need for subsequent infrainguinal bypass (P = .034). CONCLUSIONS Isolated CFE as primary therapy in highly selected patients with CLTI was safe and effective. Index limb stage is predictive of the need for associated infrainguinal revascularization in this complex population.
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Affiliation(s)
- Michael Chaney
- Department of Surgery, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI
| | - Gaurang Joshi
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | | | - Mohammed Rashid
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Abraham Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Chad E Jacobs
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Lewis B Schwartz
- Department of Surgery, Advocate Lutheran General Hospital, Park Ridge, IL
| | - Rym El Khoury
- Department of Surgery, Division of Vascular Surgery, NorthShore University Health System, Evanston, IL.
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Okabe H, Doi H, Umeda M, Takeo M, Nakamura Y, Motozato K, Furukawa S, Kawakami K, Abe K, Matsumura T, Kataoka M. Proximal superficial femoral artery puncture using an ascending approach for stent re-occlusion in the common femoral artery. J Cardiol Cases 2024; 29:205-208. [PMID: 39100512 PMCID: PMC11295016 DOI: 10.1016/j.jccase.2024.01.003] [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: 09/05/2023] [Revised: 12/01/2023] [Accepted: 01/03/2024] [Indexed: 08/06/2024] Open
Abstract
We aimed to describe a technique for approaching the common femoral artery (CFA) in cases where doing so is difficult owing to an occluded lesion caused by a previously implanted stent. A 72-year-old woman had severe stenotic lesions in both iliac arteries that required an approach via the bilateral femoral arteries. The right CFA had a previously implanted stent and a completely occluded lesion that extended from the superficial femoral artery (SFA). A 20G needle was inserted through the proximal SFA, and the needle tip was advanced into the CFA stent and passed through the occluded lesion using a microcatheter and guide wire (GW). This allowed us to insert a guide catheter via the GW into the occluded lesion. No complications, such as bleeding, were observed after the procedure. When the CFA is occluded by a stent, an ascending approach through the proximal SFA is a viable treatment option. Learning objective An occluded lesion due to a previously implanted stent makes approaching the common femoral artery difficult. Hence, alternative approaches are needed. In this regard, an approach via the proximal superficial femoral artery may prove useful.
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Affiliation(s)
- Hiroki Okabe
- Division of Cardiology, Kumamoto Rousai Hospital, Kumamoto, Japan
- The Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyusyu, Japan
| | - Hideki Doi
- Division of Cardiology, Kumamoto Rousai Hospital, Kumamoto, Japan
| | - Miyu Umeda
- Division of Cardiology, Kumamoto Rousai Hospital, Kumamoto, Japan
| | - Masahiro Takeo
- Division of Cardiology, Kumamoto Rousai Hospital, Kumamoto, Japan
| | - Yuki Nakamura
- Division of Cardiology, Kumamoto Rousai Hospital, Kumamoto, Japan
| | - Kota Motozato
- Division of Cardiology, Kumamoto Rousai Hospital, Kumamoto, Japan
| | - Shotaro Furukawa
- Division of Cardiology, Kumamoto Rousai Hospital, Kumamoto, Japan
| | | | - Koji Abe
- Division of Cardiology, Kumamoto Rousai Hospital, Kumamoto, Japan
| | | | - Masaharu Kataoka
- The Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyusyu, Japan
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Nwachuku EC, Farber A. Open Surgical Therapy for Peripheral Artery Disease. Curr Cardiol Rep 2024; 26:211-220. [PMID: 38342801 DOI: 10.1007/s11886-024-02027-4] [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] [Accepted: 01/25/2024] [Indexed: 02/13/2024]
Abstract
PURPOSE OF REVIEW The surgical management of symptomatic peripheral artery disease (PAD) has changed in the last few decades. Improvement in endovascular technology has resulted in more complex lesion once reserved for open surgery being addressed in an endovascular fashion. Even with these advances, there are lesions and patients that are better managed with an open surgical procedure. The aim of this review is to describe the most commonly performed open surgical procedures for PAD. RECENT FINDINGS The recently published Best Endovascular versus Best Surgical Therapy (BEST-CLI) trial was an international, prospective, randomized controlled trial that aimed to investigate which revascularization (endovascular vs. surgical bypass) approach was superior for limb salvage. The evidence supports an open surgical bypass as an initial approach. The advancements made in the surgical management of PAD have provided options for patients who were once deemed poor surgical candidates. The goal continues to be utilization of the best available tools to address patient disease. In this current era, it is important to be familiar with the open surgical therapies.
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Affiliation(s)
- Emmanuel C Nwachuku
- Department of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Alik Farber
- Department of Surgery, Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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Horie K, Takahara M, Nakama T, Tobita K, Tanaka A, Shintani Y, Tsubakimoto Y, Yoshioka N, Hayakawa N, Sasaki S, Iwata Y, Ogata K, Takagi T, Doijiri T, Fujihara M. Multicenter Registry of Common Femoral Artery Disease Treated With Endovascular Revascularization Using Interwoven Nitinol Stents: An Observational Retrospective Study. J Endovasc Ther 2024:15266028241231472. [PMID: 38369732 DOI: 10.1177/15266028241231472] [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: 02/20/2024]
Abstract
PURPOSE Surgical thromboendarterectomy has been the gold standard treatment for common femoral artery (CFA) disease. However, endovascular therapy (EVT) is conducted in certain patients with CFA lesions because of multiple comorbidities. The interwoven nitinol stent (IWS) has been developed to prevent stent fracture. Thus, this study aimed to evaluate the feasibility of EVT using IWS for CFA lesions in clinical practice. MATERIALS AND METHODS This retrospective multicenter registry analyzed patients who had symptomatic lower-extremity artery disease due to CFA lesions and underwent EVT using IWS between 2019 and 2021. The primary endpoint was restenosis 2 years after EVT. RESULTS This study enrolled a total of 177 patients with 196 CFA lesions. The 2-year estimate of freedom from restenosis was 88.0%. The 2-year freedom rates from the target-lesion revascularization, major amputation, and all-cause death were 92.9%, 99.0%, and 75.2%, respectively. The clinical features significantly associated with restenosis risk were the reference vessel diameter (RVD, per 1.0 mm, hazard ratio [HR], 0.24 [0.08-0.70]; p=0.009), external iliac artery (EIA) involvement (HR=4.03 [1.56-10.4]; p=0.004), superficial femoral artery (SFA) involvement (HR=3.05 [1.00-9.25]; p=0.049), body mass index (BMI; per 1.0, HR=0.85 [0.73-0.99]; p=0.032), occlusion of deep femoral arteries (DFAs) at baseline (HR=7.89 [2.04-30.5]; p=0.003), and chronic limb-threatening ischemia (CLTI, HR=2.63 [1.02-6.78]; p=0.045). Their significant association was also confirmed by the random survival forest analysis. During a median follow-up of 12.0 months, guiding sheaths were inserted via CFAs implanted IWSs in 73 cases (37.2%), and no patients had cannulation-related complications, such as failed hemostasis, fracture of IWS, and stent occlusion. CONCLUSIONS Endovascular therapy using IWS in CFA lesions showed acceptable 2-year patency rates at 88.0% and might preserve the arterial access via the ipsilateral CFAs. Small RVD, involving EIA and SFA lesions, emaciation, occluded DFA, and CLTI are associated with poor 2-year patency rates following EVT, thus, IWS implantation in CFA lesions may be an option for patients unsuitable for surgical revascularization. CLINICAL IMPACT This retrospective multicenter registry enrolled 177 patients with 199 CFA lesions treated with EVT using interwoven nitinol stents, because surgical thromboendarterectomy was difficult due to their multiple comorbidities. The 2-year estimate of freedom from restenosis was acceptable at 88.0%. The 2-year freedom rate from major amputation was also high at 99.0%. Moreover, during a median follow-up of 12.0 months, guiding sheaths were inserted via CFAs implanted IWSs in 73 cases, and no patients had cannulation-related complications such as failed hemostasis, fracture of IWS, and stent occlusion.
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Affiliation(s)
- Kazunori Horie
- Department of Cardiovascular Medicine, Sendai Kousei Hospital, Sendai, Japan
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tatsuya Nakama
- Department of Cardiology, Tokyo Bay Medical Center, Urayasu, Japan
| | - Kazuki Tobita
- Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Japan
| | - Akiko Tanaka
- Department of Cardiovascular Medicine, Sendai Kousei Hospital, Sendai, Japan
| | - Yoshiaki Shintani
- Department of Cardiology, Ageo Central General Hospital, Ageo, Japan
| | | | - Naoki Yoshioka
- Department of Cardiology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Naoki Hayakawa
- Department of Cardiovascular Medicine, Asahi General Hospital, Asahi, Japan
| | - Shinya Sasaki
- Department of Cardiology, Saka General Hospital, Shiogama, Japan
| | - Yo Iwata
- Department of Cardiology, Funabashi Municipal Medical Center, Funabashi, Japan
| | - Kenji Ogata
- Cardiovascular Center, Miyazaki Medical Association Hospital, Miyazaki, Japan
| | - Tomonari Takagi
- Cardiovascular Center, Takatsu General Hospital, Kawasaki, Japan
| | - Tatsuki Doijiri
- Department of Cardiology, Yamato Seiwa Hospital, Yamato, Japan
| | - Masahiko Fujihara
- Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan
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Ahmic E, Hitzl W, Seitelberger R, Linni K. Using Isolated Femoral Bifurcation Endarterectomy or Combined with Bypass Surgery for Patients with Chronic Limb-Threatening Ischemia. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:316. [PMID: 38399603 PMCID: PMC10890108 DOI: 10.3390/medicina60020316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 01/30/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: The aim of this study was to evaluate the clinical outcomes of patients suffering from chronic limb-threatening ischemia (CLTI) and tissue loss treated with primary isolated femoral bifurcation endarterectomy (FBE) or with FBE combined with bypass surgery. Materials and Methods: This retrospective study was performed in a tertiary university-based care centre. Between January 2008 and December 2019, a prospectively collected database of patients suffering from CLTI and tissue loss and undergoing either primary FBE (group A) or FBE in combination with bypass surgery (group B) was analysed. Study endpoints were ulcer healing, primary and secondary patency rate, limb salvage, and survival. Results: In total, FBE was performed in 73 patients and FBE with bypass in 60 patients. Between both groups, there were no significant differences regarding demographic data or the Global Limb Anatomic Staging System (GLASS) grade III and IV of femoropopliteal lesions. After 3 years, ulcer healing could be achieved in 72% of FBE and in 75% of FBE with bypass patients. The primary patency rate was 95% and 91% for FBE and 83% and 80% for FBE with bypass after one and three years, respectively. The 3-year limb-salvage rate was 78% for FBE and 84% for FBE with bypass. The secondary patency rate after one and three years was 99% and 97% for FBE and 93% and 88% for FBE with bypass. Conclusions: FBE and FBE with bypass are equally effective for ulcer healing in cases of combined CFA and superficial femoral artery lesions. There was no significant difference between both groups regarding primary and secondary patency rates, limb salvage rates and ulcer healing. Isolated FBE could be an alternative strategy in patients with higher operative risk.
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Affiliation(s)
- Edin Ahmic
- Department of Cardiovascular and Endovascular Surgery, Paracelsus Medical University Salzburg, Müllner Hauptstrasse 48, A-5020 Salzburg, Austria; (R.S.); (K.L.)
| | - Wolfgang Hitzl
- Research Office (Biostatistics), Paracelsus Medical University, Müllner Hauptstrasse 48, A-5020 Salzburg, Austria;
| | - Rainald Seitelberger
- Department of Cardiovascular and Endovascular Surgery, Paracelsus Medical University Salzburg, Müllner Hauptstrasse 48, A-5020 Salzburg, Austria; (R.S.); (K.L.)
| | - Klaus Linni
- Department of Cardiovascular and Endovascular Surgery, Paracelsus Medical University Salzburg, Müllner Hauptstrasse 48, A-5020 Salzburg, Austria; (R.S.); (K.L.)
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9
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Gallagher KA, Mills JL, Armstrong DG, Conte MS, Kirsner RS, Minc SD, Plutzky J, Southerland KW, Tomic-Canic M. Current Status and Principles for the Treatment and Prevention of Diabetic Foot Ulcers in the Cardiovascular Patient Population: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e232-e253. [PMID: 38095068 PMCID: PMC11067094 DOI: 10.1161/cir.0000000000001192] [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] [Indexed: 01/24/2024]
Abstract
Despite the known higher risk of cardiovascular disease in individuals with type 2 diabetes, the pathophysiology and optimal management of diabetic foot ulcers (DFUs), a leading complication associated with diabetes, is complex and continues to evolve. Complications of type 2 diabetes, such as DFUs, are a major cause of morbidity and mortality and the leading cause of major lower extremity amputation in the United States. There has recently been a strong focus on the prevention and early treatment of DFUs, leading to the development of multidisciplinary diabetic wound and amputation prevention clinics across the country. Mounting evidence has shown that, despite these efforts, amputations associated with DFUs continue to increase. Furthermore, due to increasing patient complexity of management secondary to comorbid conditions, such as cardiovascular disease, the management of peripheral artery disease associated with DFUs has become increasingly difficult, and care delivery is often episodic and fragmented. Although structured, process-specific approaches exist at individual institutions for the management of DFUs in the cardiovascular patient population, there is insufficient awareness of these principles in the general medicine communities. Furthermore, there is growing interest in better understanding the mechanistic underpinnings of DFUs to better define personalized medicine to improve outcomes. The goals of this scientific statement are to provide salient background information on the complex pathogenesis and current management of DFUs in cardiovascular patients, to guide therapeutic and preventive strategies and future research directions, and to inform public policy makers on health disparities and other barriers to improving and advancing care in this expanding patient population.
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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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11
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Okazaki T, Kobayashi T, Mochizuki S, Ozawa M, Maeda K, Inoue R, Futagami D, Tachibana H, Sato K, Hiraoka T, Tomota M, Emura S, Shimizu H, Takasaki T, Kodama H, Takahashi S. Clinical Outcomes of Common Femoral Thromboendarterectomy with Bovine Pericardium Patch Angioplasty. Ann Vasc Surg 2024; 98:194-200. [PMID: 37385339 DOI: 10.1016/j.avsg.2023.06.010] [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: 03/17/2023] [Revised: 05/26/2023] [Accepted: 06/01/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND The purpose of the study is to evaluate the efficacy of thromboendarterectomy (TEA) for common femoral occlusive disease using bovine pericardium patch angioplasty. METHODS The subjects were patients who underwent TEA for common femoral occlusive disease with bovine pericardium patch angioplasty from October 2020 to August 2021. The study had a prospective, multicenter, and observational design. The primary end point was primary patency (freedom from restenosis). The secondary end points were secondary patency, amputation-free survival (AFS), postoperative wound complication, hospital death within 30 days, and major adverse cardiovascular events (MACE) within 30 days. RESULTS Forty-seven TEA procedures with a bovine patch were performed in 42 patients (34 males; median age, 78 years; diabetes mellitus, 57%; end-stage renal disease with hemodialysis, 19%). Clinical presentations were intermittent claudication (68%) and critical limb-threatening ischemia (32%). Sixteen (34%) limbs underwent TEA alone and 31 (66%) underwent a combined procedure. Surgical site infection (SSI) occurred in 4 limbs (9%) and lymphatic fistulas in 3 limbs (6%). One limb with SSI required surgical debridement 19 days after the procedure, and 1 limb (2%) without postoperative wound complications required additional treatment due to acute bleeding. Hospital death within 30 days occurred in 1 case due to panperitonitis. There was no MACE within 30 days. Claudication was improved in all cases. Postoperative ABI of 0.92 [0.72-1.00] was significantly higher than the preoperative value (P < 0.001). The median follow-up period was 10 months [9-13 months]. One limb (2%) required additional endovascular therapy due to stenosis at the endarterectomy site at 5 months postoperatively. Primary and secondary patencies were 98% and 100% at 12 months, respectively, and the AFS rate was 90% at 12 months. CONCLUSIONS Common femoral TEA with bovine pericardium patch angioplasty has satisfactory clinical outcomes.
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Affiliation(s)
- Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan.
| | - Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Shingo Mochizuki
- Department of Cardiovascular Surgery, Akane-Foundation Tsuchiya General Hospital, Hiroshima-shi, Hiroshima, Japan
| | - Masamichi Ozawa
- Department of Cardiovascular Surgery, Hiroshima Prefectural Hospital, Hiroshima-shi, Hiroshima, Japan
| | - Kazuki Maeda
- Department of Cardiovascular Surgery, National Hospital Organization Higashihiroshima Medical Center, Higashihiroshima-shi, Hiroshima, Japan
| | - Risa Inoue
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima-shi, Hiroshima, Japan
| | - Daisuke Futagami
- Department of Cardiovascular Surgery, Fukuyama Cardiovascular Hospital, Fukuyama-shi, Hiroshima, Japan
| | - Hitoshi Tachibana
- Department of Cardiovascular Surgery, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima-shi, Hiroshima, Japan
| | - Katsutoshi Sato
- Department of Cardiovascular Surgery, JA Onomichi General Hospital, Onomichi-shi, Hiroshima, Japan
| | - Toshifumi Hiraoka
- Department of Cardiovascular Surgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Kure-shi, Hiroshima, Japan
| | - Mayu Tomota
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Shogo Emura
- Department of Cardiovascular Surgery, National Hospital Organization Higashihiroshima Medical Center, Higashihiroshima-shi, Hiroshima, Japan
| | - Haruna Shimizu
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima-shi, Hiroshima, Japan
| | - Taiichi Takasaki
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima-shi, Hiroshima, Japan
| | - Hiroshi Kodama
- Department of Cardiovascular Surgery, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima-shi, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University Hospital, Hiroshima-shi, Hiroshima, Japan
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Colacchio EC, Salcuni M, Gasparre A, Giorgio D, Barile D, Bussetti F, Antonello M, Colacchio G. Midterm Results of Intravascular Lithotripsy for Severely Calcified Common Femoral Artery Occlusive Disease: A Single-Center Experience. J Endovasc Ther 2023; 30:859-866. [PMID: 35766412 DOI: 10.1177/15266028221105188] [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] [Indexed: 11/16/2022]
Abstract
PURPOSE Common femoral artery (CFA)-occlusive disease has traditionally been treated with open surgery, yet nowadays the frailty of patients has induced to find new techniques of revascularisation by endovascular means. So far, intravascular lithotripsy (IVL) has shown promising results in several lower limbs arterial districts. The purpose of this article is to report our experience with IVL for severely calcified peripheral arterial disease (PAD) of the CFA. METHODS From November 2018 and October 2020, 10 consecutive patients (12 limbs) treated with IVL were prospectively enrolled in a dedicated database. Inclusion criteria were CFA localization of PAD, with a severe degree of calcification, a lesion length ≥10 mm, and a degree of stenosis ≥70% (severe). The only admitted adjunctive treatment was drug-coated balloon (DCB) angioplasty. Primary outcomes were technical and procedural success, clinical success, and target lesion revascularisation (TLR). Secondary outcomes were target extremity revascularisation (TER) and major adverse events (MAEs). RESULTS All patients underwent IVL with associated DCB angioplasty. The median percentage of achieved stenosis reduction was 55.5% (interquartile range [IQR] 50-60.75), with a technical and procedural success of 100%. Over the study period, TLR only occurred in one limb (8.3%), with a mean upgrade in Rutherford class of 2.7 ± 0.77. No target vessel and access site complications were reported, as well as no distal embolization. One death and one major amputation occurred over the follow-up period, both in the same patient. CONCLUSIONS Based on our experience, IVL for selected cases of severely calcified CFA disease, associated with DCB angioplasty, may be considered a safe and effective technique. Of course, a long-term follow-up and a larger series of patients are needed to validate our results.
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Affiliation(s)
- Elda Chiara Colacchio
- Vascular and Endovascular Surgery Section, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Matteo Salcuni
- Interventional Radiologist, Marrelli Hospital, Crotone, Italy
| | - Angelo Gasparre
- Department of Vascular and Endovascular Surgery, General Regional Hospital Ente Ecclesiastico "F. Miulli," Acquaviva Delle Fonti, Italy
| | - Donato Giorgio
- Department of Vascular and Endovascular Surgery, General Regional Hospital Ente Ecclesiastico "F. Miulli," Acquaviva Delle Fonti, Italy
| | - Domenico Barile
- Department of Vascular and Endovascular Surgery, General Regional Hospital Ente Ecclesiastico "F. Miulli," Acquaviva Delle Fonti, Italy
| | - Francesco Bussetti
- Department of Vascular and Endovascular Surgery, General Regional Hospital Ente Ecclesiastico "F. Miulli," Acquaviva Delle Fonti, Italy
| | - Michele Antonello
- Vascular and Endovascular Surgery Section, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Giovanni Colacchio
- Department of Vascular and Endovascular Surgery, General Regional Hospital Ente Ecclesiastico "F. Miulli," Acquaviva Delle Fonti, Italy
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Vakhitov D, Salminen A, Protto S. To patch, or not to patch a common femoral artery, that is the question. Vascular 2023:17085381231174702. [PMID: 37155584 DOI: 10.1177/17085381231174702] [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: 05/10/2023]
Abstract
OBJECTIVES There is no strong evidence to support or reject the use of patch angioplasty (PA) after femoral endarterectomy (FE). The current study aimed to assess early postoperative complications and compare primary patency (PP) rates after FE in patients treated with PA versus direct closure (DC). METHODS This is a retrospective study of patients admitted during 06/2002-07/2017 with signs and symptoms of chronic lower limb ischemia (Rutherford categories 2-6). Patients with angiographically confirmed stenoses or occlusions of the common femoral arteries (CFAs) and managed with FE with or without PA were included in the study. Early postoperative wound complications were assessed. The PP analysis was based on imaging-confirmed data. The impact of PA on the patency was evaluated in a confounder-adjusted Cox regression model. PP rates were compared with log-rank between the PA and DC groups using Kaplan-Meier survival analysis in the propensity score-matched (PSM) cohorts. RESULTS A total of 295 primary FEs were identified. The patients' median age was 75 years. A total of 210 patients were managed with PA and 85 with DC. Altogether, 38 (12.9%) local wound complications were registered, 15 (5.1%) of which required re-interventions. There were 9 (3.2%) cases of deep wound infection, 20 (7.0%) seromas, and 11 (3.9%) cases of major bleeding, with no significant difference between the PA and DC groups. All of the infected patches were made of synthetic material, and 83% of them were removed. The PP analysis was performed on 50 PSM patient pairs with a median age of 74 years. The median imaging-confirmed follow-up lengths were 77 months (IQR = 47 months) for the PA patients and 27 months (IQR = 64 months) for the DC patients. The preoperative median diameter of the CFA was 8.8 mm (IQR = 3.4). The 5 year primary patency rates of CFAs with a minimum diameter of 5.5 mm managed with PA or DC exceeded 91%, p > 0.05. Female sex was associated with the loss of PP, odds ratio 4.17, p = 0.046. CONCLUSIONS Wound complications after FE with or without patching are not uncommon and often lead to reoperations. The PP rates of CFAs with a minimum diameter of 5.5 mm and accomplished with or without patching are comparable. Female sex is associated with the loss of patency.
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Affiliation(s)
- Damir Vakhitov
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Akseli Salminen
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Sara Protto
- Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
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Nguyen HT, Peirsman A, Tirpakova Z, Mandal K, Vanlauwe F, Maity S, Kawakita S, Khorsandi D, Herculano R, Umemura C, Yilgor C, Bell R, Hanson A, Li S, Nanda HS, Zhu Y, Najafabadi AH, Jucaud V, Barros N, Dokmeci MR, Khademhosseini A. Engineered Vasculature for Cancer Research and Regenerative Medicine. MICROMACHINES 2023; 14:978. [PMID: 37241602 PMCID: PMC10221678 DOI: 10.3390/mi14050978] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/10/2023] [Accepted: 04/19/2023] [Indexed: 05/28/2023]
Abstract
Engineered human tissues created by three-dimensional cell culture of human cells in a hydrogel are becoming emerging model systems for cancer drug discovery and regenerative medicine. Complex functional engineered tissues can also assist in the regeneration, repair, or replacement of human tissues. However, one of the main hurdles for tissue engineering, three-dimensional cell culture, and regenerative medicine is the capability of delivering nutrients and oxygen to cells through the vasculatures. Several studies have investigated different strategies to create a functional vascular system in engineered tissues and organ-on-a-chips. Engineered vasculatures have been used for the studies of angiogenesis, vasculogenesis, as well as drug and cell transports across the endothelium. Moreover, vascular engineering allows the creation of large functional vascular conduits for regenerative medicine purposes. However, there are still many challenges in the creation of vascularized tissue constructs and their biological applications. This review will summarize the latest efforts to create vasculatures and vascularized tissues for cancer research and regenerative medicine.
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Affiliation(s)
- Huu Tuan Nguyen
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
| | - Arne Peirsman
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
- Plastic, Reconstructive and Aesthetic Surgery, Ghent University Hospital, 9000 Ghent, Belgium
| | - Zuzana Tirpakova
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
- Department of Biology and Physiology, University of Veterinary Medicine and Pharmacy in Kosice, Komenskeho 73, 04181 Kosice, Slovakia
| | - Kalpana Mandal
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
| | - Florian Vanlauwe
- Plastic, Reconstructive and Aesthetic Surgery, Ghent University Hospital, 9000 Ghent, Belgium
| | - Surjendu Maity
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
| | - Satoru Kawakita
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
| | - Danial Khorsandi
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
| | - Rondinelli Herculano
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
- Bioengineering & Biomaterials Group, School of Pharmaceutical Sciences, São Paulo State University (UNESP), Araraquara 14800-903, SP, Brazil
| | - Christian Umemura
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
| | - Can Yilgor
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
| | - Remy Bell
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
| | - Adrian Hanson
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
| | - Shaopei Li
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
| | - Himansu Sekhar Nanda
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
- Biomedical Engineering and Technology Laboratory, PDPM—Indian Institute of Information Technology Design Manufacturing, Jabalpur 482005, Madhya Pradesh, India
| | - Yangzhi Zhu
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
| | | | - Vadim Jucaud
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
| | - Natan Barros
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
| | | | - Ali Khademhosseini
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA 90064, USA
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15
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Uehara H, Uchiyama M, Imazuru T, Shimokawa T. A successful case of patch angioplasty with bovine pericardium XenoSure® to the common femoral artery after endarterectomy. Int J Surg Case Rep 2023; 106:108209. [PMID: 37075500 DOI: 10.1016/j.ijscr.2023.108209] [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: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/21/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE The number of patients with chronic limb-threatening ischemia has increased in recent years. Herein, we report a rare case of angioplasty with a bovine pericardial patch in a patient with severe stenosis of the common femoral artery. CASE PRESENTATION We report a case of a 73-year-old female with intermittent claudication. Ankle-brachial index (ABI) measurements showed a significant decrease of 0.52 on the left, and angiography revealed total occlusion on the left common femoral artery (CFA). Considering additional skin incisions, postoperative wound infection, and potential graft sampling, endarterectomy of the left CFA and patch angioplasty with the bovine pericardium (XenoSure®) were performed. The operative computed tomography showed no stenosis and the ABI improved from 0.52 to 1.15. Additionally, no stenosis, calcification, or dilatation was observed during the follow-up one year after the operation. CLINICAL DISCUSSION Various types of peripheral arterial repair were performed after endarterectomy. Autologous vein grafts and vascular prostheses are frequently used considering the background of each patient. Using bovine pericardium over other devices has several advantages, including no additional skin incisions to obtain the patches, resistance to infection, no oozing from the device itself, less bleeding from the suture site, and ease of hemostasis after the puncture under additional endovascular treatment. This case may be a good implication when deciding which device to use in complicated patients. CONCLUSION This case provides valuable insight into successful patch angioplasty after endarterectomy without any complications, highlighting the utility of XenoSure® in the treatment of this disease.
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Affiliation(s)
- Hiroo Uehara
- Department of Cardiovascular Surgery, Teikyo University Hospital, Tokyo, Japan.
| | - Masateru Uchiyama
- Department of Cardiovascular Surgery, Teikyo University Hospital, Tokyo, Japan.
| | - Tomohiro Imazuru
- Department of Cardiovascular Surgery, Teikyo University Hospital, Tokyo, Japan.
| | - Tomoki Shimokawa
- Department of Cardiovascular Surgery, Teikyo University Hospital, Tokyo, Japan.
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16
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Long-Term Outcomes following Common Femoral Endarterectomy. J Clin Med 2022; 11:jcm11226873. [PMID: 36431350 PMCID: PMC9697575 DOI: 10.3390/jcm11226873] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/08/2022] [Accepted: 11/18/2022] [Indexed: 11/23/2022] Open
Abstract
Thromboendarterectomy of the common femoral artery (CFA) for occlusive disease is a crucial procedure in vascular surgery. As an outcome reference for emerging endovascular procedures and new devices, we need more robust evidence of the outcome of this gold standard technique. The purpose of this study was to report 10-year results after femoral endarterectomy (FEA). A retrospective review of medical records at our institution identified eighty consecutive patients (91 limbs) who underwent FEA for CFA lesions. Indications for FEA included 50 limbs (55%) for intermittent claudication (IC) and 39 limbs (43%) with chronic limb-threatening ischemia (CLTI). Two limbs (2%) underwent FEA to prevent hemodynamic steal during extra-anatomical bypass. Adjunctive procedures included endovascular therapy in 32%. CFAs were closed with patch angioplasty in 44%. With a mean follow-up period of 39 months, the survival rates at 3 and 8 years were 85% and 77%, respectively. Limb salvage rates were 92% and 87%. Primary patencies were 98% and 84%. Freedom from target lesion revascularization was 95% at 3 years and 91% at 8 years. Our findings support the durability of FEA, with comparable long-term procedural results in CLTI patients as well as IC patients. Since the FEA is a gate maneuver for hybrid revascularization in CLTI patients, our findings support a strategy combining open and endovascular approaches. Femoral endarterectomy remains a durable solution for common femoral occlusive disease in IC and CLTI in the era of endovascular therapy.
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17
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Marie Hoffmann-Wieker C, Ronellenfitsch U, Rebelo A, Görg N, Schwarzer G, Ballotta E, Gouëffic Y, Böckler D. Open Surgical Thrombendarterectomy Versus Endovascular Treatment in Occlusive Processes of the Femoral Artery Bifurcation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2022; 119:803-809. [PMID: 36424715 PMCID: PMC9906024 DOI: 10.3238/arztebl.m2022.0331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 12/07/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The standard treatment of occlusive processes of the femoral artery bifurcation is thrombendarterectomy (TEA). Endovascular techniques (ENDO) have recently been put forward as a potential alternative. It is unclear so far which modality yields better outcomes with respect to long-term revascularization and periprocedural complications. Method: Multiple databases were systematically searched for pertinent publications (publication date November 1965 to February 2022). From the included studies, individual patient data (IPD) were requested. Aggregate data (AD) were used when no IPD were available. Primary and secondary patency (PP and SP), perioperative morbidity/mortality, and further endpoints were determined separately for TEA and ENDO and compared with each other. AD for each modality were summarized in meta-analyses. Time-to-event analyses and comparative meta-analyses with PP as primary endpoint were carried out using IPD. Results: 42 studies (3 IPD, 39 AD; 27 TEA, 12 ENDO, 3 comparisons of TEA versus ENDO) were included. In the combined meta-analysis of IPD and AD, PP for TEA was 97% at 6 months and 92% at 12 months, while PP for ENDO was 84% at 6 months and 85% at 12 months. The differences were not statistically significant. The comparative meta-analysis regarding PP did not reveal any significant differences either (TEA versus ENDO: HR 0.30 [0.06; 1.48]). SP at 12 months was 97% (TEA) and 93% (ENDO). The periprocedural morbidity was 16% for TEA and 9% for ENDO. Conclusion: In light of a higher PP, even without formal statistical proof of superiority, TEA can still be considered the standard treatment for occlusive processes of the femoral artery bifurcation. METHODS Multiple databases were systematically searched for pertinent publications (publication date November 1965 to February 2022). From the included studies, individual patient data (IPD) were requested. Aggregate data (AD) were used when no IPD were available. Primary and secondary patency (PP and SP), perioperative morbidity/mortality, and further endpoints were determined separately for TEA and ENDO and compared with each other. AD for each modality were summarized in meta-analyses. Time-to-event analyses and comparative meta-analyses with PP as primary endpoint were carried out using IPD. RESULTS 42 studies (3 IPD, 39 AD; 27 TEA, 12 ENDO, 3 comparisons of TEA versus ENDO) were included. In the combined meta-analysis of IPD and AD, PP for TEA was 97% at 6 months and 92% at 12 months, while PP for ENDO was 84% at 6 months and 85% at 12 months. The differences were not statistically significant. The comparative meta-analysis regarding PP did not reveal any significant differences either (TEA versus ENDO: HR 0.30 [0.06; 1.48]). SP at 12 months was 97% (TEA) and 93% (ENDO). The periprocedural morbidity was 16% for TEA and 9% for ENDO. CONCLUSION In light of a higher PP, even without formal statistical proof of superiority, TEA can still be considered the standard treatment for occlusive processes of the femoral artery bifurcation.
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Affiliation(s)
- Carola Marie Hoffmann-Wieker
- *These authors share first authorship.,Department of Vascular and Endovascular Surgery, Heidelberg University Hospital,*Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie Universitätsklinikum Heidelberg Im Neuenheimer Feld 420, 69120 Heidelberg, Germany
| | - Ulrich Ronellenfitsch
- *These authors share first authorship.,Department of Visceral, Vascular and Endocrine Surgery, University Medical Center, Martin-Luther-University Halle-Wittenberg (Saale)
| | - Artur Rebelo
- Department of Visceral, Vascular and Endocrine Surgery, University Medical Center, Martin-Luther-University Halle-Wittenberg (Saale)
| | - Nadine Görg
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital
| | - Guido Schwarzer
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Center, Albert-Ludwigs-University of Freiburg
| | - Enzo Ballotta
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, School of Medicine, Padova, Italy
| | - Yann Gouëffic
- Department of Vascular Surgery, University Hospital of Nantes, France
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital
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Liu P, Zheng LH, He XQ, Yang Y, Zhang LK, Zhang L, Zhang F. Mid-Term Outcomes of Endovascular Therapy for TASC II D Femoropopliteal Lesions with Critical Limb Ischaemia: A Retrospective Analysis. Ann Vasc Surg 2022; 88:182-190. [PMID: 36007776 DOI: 10.1016/j.avsg.2022.08.004] [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: 06/13/2022] [Revised: 07/17/2022] [Accepted: 08/07/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study evaluated the mid-term results of endovascular therapy (EVT) for Trans-Atlantic Inter-Society (TASC) II D femoropopliteal lesions in patients with critical limb ischaemia (CLI). METHODS Fifty-seven limbs of 54 patients with CLI due to TASC II D femoropopliteal lesions who underwent EVT at the First Hospital of Hebei Medical University were retrospectively analysed in single-centre, observational study. The patient characteristics, endovascular procedural details, freedom from target lesion revascularisation (TLR), patency rates, ulcer healing rate, and limb salvage rate were accessed. RESULTS The patients' mean age was 68.2 ± 8.2 years. All patients were treated by EVT. The final technical success rate was 98.2% (56/57). There were 23 cases of pain at rest, 18 cases of ulcer, and 15 cases of gangrene. The median length of the treated segment was 286 ± 42 mm (56/56) and the mean number of stents placed per patient was 2.0 ± 0.8 (49/56). The postoperative ankle-brachial index (ABI) was significantly higher than that of the preoperative ABI (P < 0.05). The perioperative complication rate was 10.7% (6/56). The re-stenosis or occlusion rate was 44.6% (25/56). The estimated rates of freedom from TLR at 1 year, 2 years, and 3 years were 86.8%, 67.0%, and 62.5%, respectively. Univariate analysis showed that predictors of freedom from TLR were the number of runoff vessels, length of the lesion, and complexity of the lesion, while predictors for re-stenosis or occlusion were the length and the complexity of the lesion. The ulcer healing rate was 93.8%. The limb salvage rates were 76.4%, 74.4%, and 70.9% at 1, 2, and 3 years after treatment, respectively. CONCLUSIONS The mid-term outcomes of EVT for TASC II D femoropopliteal lesions in patients with CLI indicated that this treatment approach is safe and effective, and is clinically applicable.
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Affiliation(s)
- Peng Liu
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Li-Hua Zheng
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Xin-Qi He
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Yan Yang
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Li-Ke Zhang
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Lei Zhang
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China
| | - Feng Zhang
- Department of Vascular and Endovascular Surgery, Hebei Key Laboratory of Colorectal Cancer Precision Diagnosis and Treatment, the First Hospital of Hebei Medical University, Shijiazhuang, Hebei 050031, PR China.
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19
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Nakama T, Takahara M, Iwata Y, Fujimura N, Yamaoka T, Suzuki K, Obunai K. 1-Year Outcomes of Thromboendarterectomy vs Endovascular Therapy for Common Femoral Artery Lesions: CAULIFLOWER Study Results. JACC Cardiovasc Interv 2022; 15:1453-1463. [PMID: 35863795 DOI: 10.1016/j.jcin.2022.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/28/2022] [Accepted: 03/08/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Thromboendarterectomy (TEA) is the gold-standard treatment for common femoral artery (CFA). However, because of its low invasiveness and short hospitalization duration, CFA endovascular therapy (EVT) is performed in real-world practice. However, the clinical benefits and appropriate target population for CFA EVT remain unclear. OBJECTIVES The aims of this study were to compare the clinical outcomes of TEA with those of EVT in patients with symptomatic CFA diseases and to identify the adequate target population for CFA EVT. METHODS A total of 1,193 consecutive patients who underwent EVT (n = 761) or TEA (n = 432) for CFA were identified and retrospectively reviewed from a registry of 66 institutions. The primary outcome was 1-year primary patency compared between EVT and TEA using propensity score matching. An interaction analysis was performed to explore the appropriate target population for CFA EVT. RESULTS After propensity score matching, the 1-year primary patency rate was significantly higher in the TEA group (82.3% vs 96.6%; P < 0.001), whereas perioperative complications were more frequently observed in the TEA group (P = 0.047). Nonambulatory status attenuated the HR of EVT vs TEA for restenosis risk (P = 0.021), whereas the presence of nodular calcification significantly increased the HR (P = 0.040). In the EVT subgroup analysis for restenosis risk, stent use showed the lowest HR compared with plain balloon angioplasty and drug-coated balloon angioplasty (P < 0.001). CONCLUSIONS TEA showed superior 1-year patency compared with EVT in a nationwide multicenter study. Nonambulatory status attenuated the superiority, whereas the presence of nodular calcification enhanced it.
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Affiliation(s)
- Tatsuya Nakama
- Department of Cardiology, Tokyo Bay Medical Center, Urayasu, Japan.
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yo Iwata
- Department of Cardiology, Heart & Vascular Institute, Funabashi Municipal Medical Center, Funabashi, Japan
| | - Naoki Fujimura
- Department of Vascular Surgery, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Ehime, Japan
| | - Kenji Suzuki
- Department of Cardiology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Kotaro Obunai
- Department of Cardiology, Tokyo Bay Medical Center, Urayasu, Japan
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20
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SUPERA Stenting in the Common Femoral Artery: Early Experience and Practical Considerations. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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21
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Edward K, Ela G. Endovascular treatment of calcific common femoral artery disease – The future or even present. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 43:85-86. [DOI: 10.1016/j.carrev.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 07/21/2022] [Indexed: 11/03/2022]
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22
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Ravikumar N, Sreejith G, Law SHC, Anand P, Varghese N, Kagdi S, Kang N, Nashnoush M, Salam S, Ongidi I. Comparative Analysis of Endovascular Intervention and Endarterectomy in Patients with Femoral Artery Disease: A Systematic Review and Meta-Analysis. Hematol Rep 2022; 14:179-202. [PMID: 35735737 PMCID: PMC9222618 DOI: 10.3390/hematolrep14020026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 03/25/2022] [Accepted: 05/26/2022] [Indexed: 11/24/2022] Open
Abstract
Peripheral artery disease is a prevalent illness affecting more than 200 million people worldwide. A commonly used technique to manage the condition has been open endarterectomy. However, in recent times, a shift towards minimally invasive techniques has resulted in endovascular intervention as a popular alternative. This review aims to assess the safety and efficacy of endovascular intervention when compared with endarterectomy. A systematic review of the articles published in PubMed, Ovid, Embase, and Scopus within the last 10 years was conducted. The PRISMA guidelines were adhered to, and the Newcastle-Ottawa and NICE quality assessment scales were used. A meta-analysis of proportions was performed using the RStudio software (RStudio Team (2021). RStudio: Integrated Development Environment for R, PBC, Boston, MA, USA). Twenty-six studies were included, with a total of 7126 patients (endovascular, 2496; endarterectomy, 4630). Technical success was greater for endarterectomy than endovascular intervention with an odds ratio of 0.38; 95% CI [0.27–0.54]. In terms of safety as well endovascular intervention was better than endarterectomy with an odds ratio of 0.22; 95% CI [0.15 to 0.31] for wound infection. Endovascular intervention is a safe and effective procedure; however, it cannot be considered superior to endarterectomy.
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Affiliation(s)
- Nidhruv Ravikumar
- Department of Medicine, School of Medicine, Queen’s University Belfast, Belfast BT7 1NN, UK;
- RadScholars Inc., Halifax, NS B3H 4R2, Canada; (S.H.C.L.); (P.A.); (N.V.); (S.K.); (N.K.); (M.N.); (S.S.); (I.O.)
- Correspondence: ; Tel.: +44-75135-44949
| | - Gopika Sreejith
- Department of Medicine, School of Medicine, Queen’s University Belfast, Belfast BT7 1NN, UK;
- RadScholars Inc., Halifax, NS B3H 4R2, Canada; (S.H.C.L.); (P.A.); (N.V.); (S.K.); (N.K.); (M.N.); (S.S.); (I.O.)
| | - Sharon Hiu Ching Law
- RadScholars Inc., Halifax, NS B3H 4R2, Canada; (S.H.C.L.); (P.A.); (N.V.); (S.K.); (N.K.); (M.N.); (S.S.); (I.O.)
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Prakhar Anand
- RadScholars Inc., Halifax, NS B3H 4R2, Canada; (S.H.C.L.); (P.A.); (N.V.); (S.K.); (N.K.); (M.N.); (S.S.); (I.O.)
- Department of Medicine, National University of Ireland, Galway, H91 TK33 Galway, Ireland
| | - Noah Varghese
- RadScholars Inc., Halifax, NS B3H 4R2, Canada; (S.H.C.L.); (P.A.); (N.V.); (S.K.); (N.K.); (M.N.); (S.S.); (I.O.)
- Department of Biochemistry, Western University, London, ON N6A 3K7, Canada
| | - Samrin Kagdi
- RadScholars Inc., Halifax, NS B3H 4R2, Canada; (S.H.C.L.); (P.A.); (N.V.); (S.K.); (N.K.); (M.N.); (S.S.); (I.O.)
- Department of Biological Sciences and Health and Society, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Navneet Kang
- RadScholars Inc., Halifax, NS B3H 4R2, Canada; (S.H.C.L.); (P.A.); (N.V.); (S.K.); (N.K.); (M.N.); (S.S.); (I.O.)
- Department of Chemistry and Chemical Biology, McMaster University, Hamilton, ON L8S 4L8, Canada
| | - Mohamed Nashnoush
- RadScholars Inc., Halifax, NS B3H 4R2, Canada; (S.H.C.L.); (P.A.); (N.V.); (S.K.); (N.K.); (M.N.); (S.S.); (I.O.)
- School of Health Sciences, Dalhousie University, Halifax, NS B3H 4R2, Canada
- IWK Health Center, Halifax, NS B3K 6R8, Canada
| | - Sihat Salam
- RadScholars Inc., Halifax, NS B3H 4R2, Canada; (S.H.C.L.); (P.A.); (N.V.); (S.K.); (N.K.); (M.N.); (S.S.); (I.O.)
- Department of Biomedical science, York University, Toronto, ON M3J 1P3, Canada
| | - Ibsen Ongidi
- RadScholars Inc., Halifax, NS B3H 4R2, Canada; (S.H.C.L.); (P.A.); (N.V.); (S.K.); (N.K.); (M.N.); (S.S.); (I.O.)
- Department of Human anatomy, School of Medicine, University of Nairobi, Nairobi P.O. Box 30197-00100, Kenya
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Evaluation of Stent Angioplasty in the Treatment of Arteriosclerotic Lesions of the Common Femoral Artery. J Clin Med 2022; 11:jcm11102694. [PMID: 35628821 PMCID: PMC9147704 DOI: 10.3390/jcm11102694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/25/2022] [Accepted: 05/07/2022] [Indexed: 11/17/2022] Open
Abstract
In many vascular segments, endovascular therapy is the treatment of choice for arteriosclerotic lesions. For the treatment of common femoral artery (CFA) lesions, surgical reconstruction is still considered the gold standard. The purpose of this study is to evaluate the safety and efficacy of stent angioplasty for the treatment of common femoral artery (CFA) lesions in a real-world population during a two-year follow up. This retrospective, single-center study includes 250 patients requiring treatment with stent angioplasty of CFA lesions. The primary end point was the target lesion revascularization (TLR) rate. Secondary end points were the overall procedural complication rate, the rate of ipsilateral CFA punctures during follow-up, changes in the Rutherford−Becker class (RBC) and ankle−brachial index (ABI), primary patency rates, amputation rate, time to and the type of TLR. A total of 236 interventions (94.4%) were successfully defined as a residual stenosis < 30%. Periinterventionally, there were 23 complications (9.1%), 3 of which had to be treated surgically. Median follow up was 21 months (average 19.2 ± 7.8). In total, 41 patients (16.4%) needed a TLR. The primary patency rate was 90.8%, 81.2% and 72% at 6, 12 and 24 months, respectively. ABI and RBC were significantly better at all time points compared to baseline. During follow up, seven amputations (three minor and four major) had to be performed. More than half of the patients (56.0%) were punctured at the stented CFA during the follow up. Multivariate logistic regression analysis showed continued nicotine use and coronary heart disease as predictors for TLR. Stent angioplasty for the treatment of CFA lesions is safe and effective. Further studies are needed to compare this endovascular option with surgical therapy.
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Sutter W, Hentgen B, Mercier L, Delattre M, Ouldsalek E, Bensaid B, Renard R, Fallouh A, Feito B, Cheysson E, Davaine JM. Surgical treatment of femoral artery bifurcation without material. Technique and follow up. Ann Vasc Surg 2022; 86:190-198. [PMID: 35513126 DOI: 10.1016/j.avsg.2022.04.027] [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: 09/24/2021] [Revised: 04/06/2022] [Accepted: 04/12/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Complete eversion of the femoral tripod is interesting to reduce clinical consequences of wound infection, in particular for patients at high risk (eg: obese, diabetics, cancer). Experience and follow up of this technique are scarce. The different technical possibilities and results are reported here. METHODS Single center prospective study including patients operated on for femoral occlusive lesions using eversion of the common femoral artery and its bifurcation. Clinical and imaging preoperative data, surgical technique and follow up are detailed. RESULTS Thirty-five patients (37 limbs) have been included between June 2014 and April 2016. Mean Rutherford index was 3.6 and 65% of the patients were claudicants. Lesions were limited to the common femoral artery in 14 (38%) of the cases and spread to the superficial femoral artery in 2 (7%) and to the three branches in 21 (57%) of the cases, respectively. Postoperatively, one death, one major amputation and 3 reinterventions were noted, resulting in a 8% rate of major complications. The mean follow up was 37 months. At this time, 11 MACE, 9 deaths and no additional major amputation were noted. The mean Rutherford index was 1.7 (P<.001) and 3 reinterventions were necessary (1 for septic occlusion at 3 months and 2 for restenosis at 12 and 42 months), translating into a primary and secondary patency rates of 93.3% and 96.1%. CONCLUSION This work further confirms that eversion of the femoral tripod is safe and effective. This experience adds to the existing body of the literature and describe alternative techniques of eversion. The technique should be considered when treating patients at high risk of postoperative infection.
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Affiliation(s)
- W Sutter
- Centre Hospitalier René Dubos, 6 Av de L'Ile-de-France, 95300 Pontoise, France
| | - B Hentgen
- Sorbonne Université, 15-21 Rue de l'École de Médecine, 75006 Paris
| | - L Mercier
- Sorbonne Université, 15-21 Rue de l'École de Médecine, 75006 Paris
| | - M Delattre
- Clinical Research Unit, Centre Hospitalier René Dubos, Pontoise, France
| | - E Ouldsalek
- Centre Hospitalier René Dubos, 6 Av de L'Ile-de-France, 95300 Pontoise, France
| | - B Bensaid
- Centre Hospitalier René Dubos, 6 Av de L'Ile-de-France, 95300 Pontoise, France
| | - R Renard
- Centre Hospitalier René Dubos, 6 Av de L'Ile-de-France, 95300 Pontoise, France
| | - A Fallouh
- Centre Hospitalier René Dubos, 6 Av de L'Ile-de-France, 95300 Pontoise, France
| | - B Feito
- Centre Hospitalier René Dubos, 6 Av de L'Ile-de-France, 95300 Pontoise, France
| | - E Cheysson
- Centre Hospitalier René Dubos, 6 Av de L'Ile-de-France, 95300 Pontoise, France
| | - J M Davaine
- Sorbonne Université, 15-21 Rue de l'École de Médecine, 75006 Paris.
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Tao MJ, Gotra A, Tan KT, Eisenberg N, Roche-Nagle G, Mafeld S. SUPERA Stenting in the Common Femoral Artery: Early Experience and Practical Considerations. Vasc Endovascular Surg 2022; 56:357-368. [PMID: 35148653 PMCID: PMC9003763 DOI: 10.1177/15385744211068648] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose Endovascular therapy in the management of de novo common femoral disease remains controversial. Considerable interest has been generated in recent years due to recent technological advancement in the design of vascular stents. In particular, SUPERA (Abbot Vascular Inc, Santa Clara USA) stents are designed to offer increased flexibility and less adverse interactions with the arterial wall, thus making it potentially better suited for common femoral lesions. However, despite such theoretical advantages, there is lack of data in its use in clinical practice. This study provides illustrative examples of SUPERA stents in different clinical settings and contributes to important clinical data for the overall efficacy and safety profile of endovascular interventions in common femoral artery (CFA) disease. Materials and Methods Retrospective analysis of all endovascular CFA procedures between January 1, 2011, and December 31, 2019, was conducted. Data collected included demographics, clinical symptoms, medical comorbidities, procedural characteristics, and immediate and short-term complications. Detailed analysis was performed on the stenting cohort. Results During our study period, a total of 69 patients underwent endovascular interventions involving the CFA at our institution, of which 16 patients had stenting procedures for a total of 18 stent deployments. Technical success was achieved in all stenting procedures. A total of 15 SUPERA stents were placed in 13 patients. No stent fractures were observed. Overall primary patency rate of SUPERA stents at the time of 12-month follow-up was 100% in patients who had a follow-up assessment (n = 12 stents). Conclusion Endovascular intervention of the CFA is an evolving topic in the interventional radiology and vascular surgery community. Recent development of newer generation of devices such as SUPERA peripheral stents offers significant potential benefits given their inherent design. Despite the theoretically promising design of the SUPERA, there is a lack of data to support its use. This study contributes important patient-level data for SUPERA stent deployments.
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Affiliation(s)
- Mary Jiayi Tao
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Joint Department of Medical Imaging, 7938University of Toronto, Toronto, ON, Canada
| | - Akshat Gotra
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, The Ottawa Hospital, 6363University of Ottawa, Ottawa, ON, Canada
| | - Kong Teng Tan
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Joint Department of Medical Imaging, 7938University of Toronto, Toronto, ON, Canada
| | - Naomi Eisenberg
- Department of Vascular Surgery, 33540Toronto General Hospital, Toronto, ON, Canada
| | - Graham Roche-Nagle
- Department of Vascular Surgery, 33540Toronto General Hospital, Toronto, ON, Canada
| | - Sebastian Mafeld
- Division of Vascular and Interventional Radiology, Department of Medical Imaging, Joint Department of Medical Imaging, 7938University of Toronto, Toronto, ON, Canada
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Rabellino M, Valle Raleigh J, Chiabrando JG, Di Caro V, Chas J, Garagoli F, Bluro I. Novel Common Femoral Artery Lesion Classification in Patients Undergoing Endovascular Revascularization. Cardiovasc Intervent Radiol 2022; 45:438-447. [DOI: 10.1007/s00270-021-03011-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/05/2021] [Indexed: 12/30/2022]
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Rodriguez S, Mangipudi S, Pomy BJ, Nguyen BN, Sidawy AN, Amdur RL, Lala S, Macsata R. A Novel Angiography Scoring System Predicts Improvement After Isolated Common Femoral Endarterectomy With Profundaplasty. Ann Vasc Surg 2021; 81:308-315. [PMID: 34743008 DOI: 10.1016/j.avsg.2021.08.046] [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: 06/30/2021] [Revised: 08/24/2021] [Accepted: 08/27/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Numerous angiography-based peripheral arterial disease classification schemes have been developed to stratify severity of preoperative patient disease, but few studies have correlated angiography-based anatomic classification schemes to postoperative outcomes. This study examined whether a proposed pre-operative angiography scoring system was predictive of outcomes after isolated common femoral endarterectomy with profundaplasty (CFEP). METHODS A retrospective review was conducted of patients treated with isolated CFEP for claudication and/or rest pain at a single institution from 2016-19. Pre-operative angiograms were assessed quantitatively by 4 blinded surgeons across 3 domains: profunda stenosis, profunda disease length, and outflow disease severity. Table I describes the proposed angiography scoring system. Internal consistency reliability of rater scores was calculated using Cronbach alpha. Outcomes included clinical improvement, further interventions, major amputations, mortality, and mean increase in ankle-brachial index (ABI) at 30 days, and 6 months. McNemar tests, between-group t-tests, Pearson correlations, and linear regression were used. RESULTS Clinical Outcomes 88% of patients (n = 22) had clinical improvement at 30 days; the remaining 12% of patients (n = 3) required further interventions. One patient (4%) required major amputation between 30 days and 6 months for recurrence of rest pain that had initially resolved after isolated CFEP. There was 0% mortality during the study period. Mean ABI increased by 0.15 ± 0.21 at 30 days, and by 0.06 ± 0.21 at 6 months. Angiography Scoring System Profunda stenosis score was associated with clinical improvement at 6 months (P = 0.04). A profunda stenosis score of ≥2.6 was strongly associated with 6-month clinical improvement (64% of those ≥ 2.6 improved, versus 15% of those <2.6, P = 0.15). Profunda stenosis score was associated with ABI improvement at 30 days (r = 0.73, P = 0.01) and 6 months (r = 0.82, P = 0.007). Profunda disease length score was associated with clinical improvement at 30 days (P = 0.002). 100% of patients with a profunda disease length score of ≥1.5 clinically improved at 30 days, versus 67% of those with <1.5 (P = 0.04). Angiography scores were not found to be associated with further intervention, major amputation, or mortality. Cronbach alpha for profunda stenosis, profunda disease length, and outflow severity scores were 0.90, 0.90, and 0.79, respectively, indicating strong internal consistency. CONCLUSIONS This institutional angiography scoring system successfully predicts clinical improvement following CFEP. Higher profunda stenosis and profunda disease length scores were most predictive of operative success within 6 months. Future validation studies will investigate these outcomes in a larger population, and over a longer period.
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Affiliation(s)
- Stephanie Rodriguez
- George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Sowmya Mangipudi
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Benjamin J Pomy
- George Washington University Hospital, Department of Surgery, Washington, DC
| | - Bao-Ngoc Nguyen
- George Washington University Hospital, Department of Surgery, Washington, DC
| | - Anton N Sidawy
- George Washington University Hospital, Department of Surgery, Washington, DC
| | - Richard L Amdur
- George Washington University Hospital, Department of Surgery, Washington, DC
| | - Salim Lala
- George Washington University Hospital, Department of Surgery, Washington, DC
| | - Robyn Macsata
- George Washington University Hospital, Department of Surgery, Washington, DC
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Early Detection of Post-Endarterectomy Complication by Point-of-Care Ultrasound. REPORTS 2021. [DOI: 10.3390/reports4030021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Endarterectomy is an effective intervention to remove the atheromatous plaque in the inner lining of the artery, aiming to revascularize the occluded/stenosed vessel in patients with peripheral arterial occlusive disease (PAOD). The most common wound-related complication is postoperative bleeding, followed by infection, hematoma, and seroma. However, hematoma complications with air surrounded have rarely been reported in clinical cases. Case presentation: A 90-year-old female patient visited our emergency department because of a rapidly growing hematoma with pulsatile bleeding over her right groin area. She had received bilateral percutaneous transluminal angioplasty with endarterectomy for PAOD one month prior. A point-of-care ultrasound revealed a large hypoechoic mass, with a dirty shadow on the right groin area. Computed tomography angiography showed a hematoma over her right femoral region, with free air surrounding the right femoral artery. Angiography revealed an irregular shaped lesion on the right femoral artery without contrast extravasation. The patient was diagnosed with right-femoral post-endarterectomy infection with infected hematoma, with the inclusion of air. She underwent urgent excision and repair of the right femoral artery infectious lesion, debridement of the infectious hematoma and stenting of the right external iliac artery, common femoral artery and superficial femoral artery.
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Böhme T, Romano L, Macharzina RR, Noory E, Beschorner U, Jacques B, Bürgelin K, Flügel PC, Zeller T, Rastan A. Outcomes of directional atherectomy for common femoral artery disease. EUROINTERVENTION 2021; 17:260-266. [PMID: 32176618 PMCID: PMC9724908 DOI: 10.4244/eij-d-19-00693] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Endovascular therapy is the first-line strategy for femoropopliteal obstructive disease. However, for lesions involving the common femoral artery (CFA) surgical endarterectomy is still the gold standard. AIMS The aim of this study was to evaluate the safety and efficacy of directional atherectomy (DA) for the treatment of CFA lesions. METHODS A retrospective analysis of patients who underwent DA of the CFA between March 2009 and June 2017 was performed. The primary efficacy endpoint was the incidence of clinically driven target lesion revascularisation (cdTLR). Secondary endpoints included the overall procedural complication rate at 30 days, change in ankle-brachial index (ABI), and Rutherford-Becker class (RBC) during follow-up. RESULTS This analysis included 250 patients. The mean follow-up period was 31.03±21.56 months (range 1-88, median follow-up period 25 months). The procedural complication rate including access-site complications, target lesion perforation, and outflow embolisation was 10.4% (n=26). All but one complication could be treated conservatively or endovascularly. One surgical revision was necessary. Freedom from major adverse events (death, cdTLR, myocardial infarction and major target limb amputation) at 30 days was 99.6%. The rate of cdTLR during follow-up was 13.6% (n=34). A significant improvement of the mean ABI and the RBC was observed. Multivariate logistic regression analysis revealed residual target lesion stenosis >30% (p=0.005), and heavy calcification of the target lesion (p=0.033) to be independent predictors for cdTLR. CONCLUSIONS The use of DA for the treatment of CFA lesions leads to promising midterm results with an acceptable complication rate.
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Affiliation(s)
- Tanja Böhme
- Angiologie und Kardiologie II, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Südring 15, 79189 Bad Krozingen, Germany
| | - Leonardo Romano
- Klinik für Angiologie, Klinikum Hochsauerland, Arnsberg, Germany
| | - Roland-Richard Macharzina
- Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Elias Noory
- Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Ulrich Beschorner
- Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Börries Jacques
- Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Karlheinz Bürgelin
- Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Peter-Christian Flügel
- Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Thomas Zeller
- Kardiologie und Angiologie II, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Aljoscha Rastan
- Medizinische Uniklinik, Angiologie, Kantonsspital Aarau, Switzerland
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Morosetti D, Chiocchi M, Argirò R, Salimei F, Nezzo M, Vidali S, Gasparrini F, Meloni M, Uccioli L, Gandini R. Endovascular treatment of calcific lesions of the common femoral artery using atherectomy device associated with scoring balloon angioplasty in diabetic patients with high "major amputation" risk. Vascular 2021; 30:463-473. [PMID: 34056973 DOI: 10.1177/17085381211019244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To investigate the outcomes of patients with calcific lesions in the common femoral artery undergoing endovascular procedures with atherectomy device and scoring balloon angioplasty combined with treatment of steno-occlusive disease of the remaining arterial districts of the lower limb. METHODS Between January 2015 and December 2018, 11 diabetic patients at high risk for "major amputation", with calcific lesions of the common femoral artery and ischemic ulcers requiring endovascular treatment were retrospectively evaluated. Technical success was defined as revascularization of the common femoral artery with a residual stenosis lower than 30%. Primary endpoints were an immediate increase of perilesional transcutaneous oxygen pressure (TCPO2) > 40 mmHg, ulcerative lesions improvement up to healing or skin flaps re-epithelialization after minor amputation, limb rescue with rejected major amputation, and resolution of rest pain if present. RESULTS The success rate of the revascularization procedures was 100%. No patient underwent surgical conversion. One case of peri-operative bleeding at the brachial access site was observed. There were no cases of arterial dissection or undesired distal embolization. The average baseline value of perilesional TCPO2 was 21.8 ± 9.2 mmHg. The mean TCPO2 value was 57.4 ± 7.2 mmHg three days after the procedure (P < 0.05), and 51.2 ± 9.8 mmHg 15 days after (P < 0.05). Minor amputations were performed in five patients with advanced ulcerative lesions. No major amputations were performed in the follow-up period. At 14 months follow-up, one patient developed new occlusion of the CFA for extension from the external iliac artery and underwent a new endovascular procedure. We observed an overall primary patency rate of 91% and a primary assisted patency rate of 100% in our 18-month follow-up. CONCLUSIONS Endovascular approach for severely calcified atherosclerotic lesions of the common femoral artery seems to represent a valid therapeutic option associated with promising results in terms of clinical outcome and low complication rates.
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Affiliation(s)
- Daniele Morosetti
- UOSD Radiologia Interventistica, University Hospital Policlinico Tor Vergata, Roma, Italy
| | - Marcello Chiocchi
- UOC Diagnostica per Immagini, University Hospital Policlinico Tor Vergata, Roma, Italy
| | - Renato Argirò
- UOSD Radiologia Interventistica, University Hospital Policlinico Tor Vergata, Roma, Italy
| | - Fabio Salimei
- UOSD Radiologia Interventistica, University Hospital Policlinico Tor Vergata, Roma, Italy
| | - Marco Nezzo
- UOSD Radiologia Interventistica, University Hospital Policlinico Tor Vergata, Roma, Italy
| | - Sofia Vidali
- UOSD Radiologia Interventistica, University Hospital Policlinico Tor Vergata, Roma, Italy
| | - Fulvio Gasparrini
- UOSD Radiologia Interventistica, University Hospital Policlinico Tor Vergata, Roma, Italy
| | - Marco Meloni
- Diabetic foot Unit, University Hospital Policlinico Tor Vergata, Roma, Italy
| | - Luigi Uccioli
- Diabetic foot Unit, University Hospital Policlinico Tor Vergata, Roma, Italy
| | - Roberto Gandini
- UOSD Radiologia Interventistica, University Hospital Policlinico Tor Vergata, Roma, Italy
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Determinants of Success and Early Complications in Common Femoral Artery Endarterectomy: A Retrospective Study. SURGERIES 2021. [DOI: 10.3390/surgeries2020019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Common femoral artery endarterectomy (CFE) is considered a relatively simple, successful and safe procedure in the literature, but major complications can occur. This retrospective study was performed in order to define characteristics contributing to success or failure after common femoral artery endarterectomy, either performed as a single or hybrid procedure. Methods: A total of 298 patients who underwent CFE in our hospital between 1 January 2011 and 1 January 2017 were included. After exclusion, 227 patients were analyzed. Patient characteristics and outcomes were derived from the patient records. Follow-up was 30 days postoperatively. Outcomes were analyzed by the chi-square test and regression analysis. Clinical success was defined as a combination of technical success, improvement in the ankle-brachial index, increased walking distance and “no complications.” Results: The procedure was clinically successful in 74.4% of the patients, and in 25.6%, a complication occurred. The Rutherford class improved in 65.1% of the patients with 1.6 (SD 1.3) class points. The ankle-brachial index improved in 44.8% of the cases, with an average of 116.6%. The most contributing factors for complications such as death, unplanned amputation, surgical site infection, thrombosis and longer hospital admission were emergency operation and a higher ASA classification. Significantly more complications also occurred in patients with renal failure, congestive heart disease, a high Rutherford classification and previous groin incision. A higher Rutherford class was the only factor correlating with an increase in the ankle-brachial index. When single CFE (48.9% of cases) and hybrid procedures (51.1%) were compared, no significant difference in success or failure was found. Conclusion: Limb ischemia requiring emergency operation and preoperative comorbidity were identified as the most important factors predictive for complications following femoral artery endarterectomy. Combining femoral endarterectomy with an endovascular intervention does not seem to increase the risk of a postoperative complication.
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Stern JR, Connolly PH, Meltzer AJ. Retrograde Endovascular With Intimal Re-Entry Through Endarterectomy: The REWIRE Technique. Ann Vasc Surg 2021; 76:218-221. [PMID: 34004322 DOI: 10.1016/j.avsg.2021.05.002] [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: 04/11/2021] [Revised: 05/05/2021] [Accepted: 05/05/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Hybrid lower extremity revascularization has been well described, typically consisting of common femoral endarterectomy (CFE) followed by direct patch puncture and endovascular treatment of any distal disease. We describe a modified technique that obviates the need for endovascular re-entry and simplifies treatment at the proximal and distal endpoints. METHODS The REWIRE technique begins with retrograde arterial access via a patent tibial, pedal or femoropopliteal vessel. The diseased segment is crossed in the subintimal plane. Once the wire reaches the common femoral artery (CFA), the vessel is surgically exposed. Arteriotomy is performed and the wire is externalized during standard CFE. With through-wire access achieved, a sheath is inserted and the distal disease is treated. The proximal extent of the endovascular revascularization is incorporated into a standard CFE with patch angioplasty. RESULTS Seven patients with chronic limb-threatening ischemia were treated with this approach, all with long segment occlusions of the SFA and significant CFA disease. The SFA disease was stented and bovine pericardial patch was used for CFE in all. Technical success was achieved in all patients. There were no complications related to the retrograde puncture site, which was controlled with manual pressure (4) or excluded with a covered stent (3). Thirty-Day freedom from major adverse limb events was 100%. CONCLUSIONS The REWIRE technique is an effective approach to hybrid revascularization involving the CFA. By crossing the occluded segment in a retrograde fashion and surgically externalizing the wire during CFE, the proximal and distal endpoints can be addressed with ease, the profunda femoris is protected under direct visualization, and the need for endovascular re-entry is eliminated.
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Affiliation(s)
| | - Peter H Connolly
- New York-Presbyterian Hospital, Weill Cornell Medicine, New York, NY
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Woronowicz-Kmiec S, Betz T, Töpel I, Bröckner S, Steinbauer M, Uhl C. Short and long-term outcome after common femoral artery hybrid procedure in patients with intermittent claudication and chronic limb threatening ischemia. VASA 2021; 50:363-371. [PMID: 33973817 DOI: 10.1024/0301-1526/a000954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: This study aimed to evaluate the differences between the outcomes of patients with intermittent claudication (IC) and chronic limb threatening ischemia (CLTI) who underwent a hybrid procedure comprising common femoral artery endarterectomy and endovascular therapy. Patients and methods: This was a retrospective single-center study of all patients with peripheral arterial occlusive disease (PAD) who underwent the hybrid procedure between March 2007 and August 2018. The primary endpoint was primary patency after 7 years. The secondary endpoints were primary-assisted patency, secondary patency, limb salvage, and survival. Results: During the follow-up period, 427 limbs in 409 patients were treated. A total of 267 and 160 patients presented with clinical signs of IC and CLTI, respectively. The 30-day mortality was 1.4% (IC: 0% vs. CLTI: 3.8%, p=0.001). The overall 30-day major amputation rate was 1.6% (IC: 0% vs. CLTI: 4.4, p=0.001). The rates of primary and secondary patency after 7 years were 63% and 94%, respectively, in the IC group and 57% and 88%, respectively, in the CLTI group; the difference was not significant. Limb salvage (94% vs. 82%, p=0.000) and survival (58% vs. 29%, p=0.000) were significantly higher in the IC group. In a multivariate analysis, CLTI was the only risk factor for major amputation. CLTI and single vessel run-off were risk factors for death. Statin therapy was a protective factor. Conclusions: The hybrid procedure provides excellent results as a treatment option for multilevel lesions in patients with PAD. However, patients with CLTI had a shorter long-term survival and lower limb salvage rate.
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Affiliation(s)
| | - Thomas Betz
- Department of Vascular Surgery, Barmherzige Brüder Hospital Regensburg, Germany
| | - Ingolf Töpel
- Department of Vascular Surgery, Barmherzige Brüder Hospital Regensburg, Germany
| | - Stefan Bröckner
- Department of Vascular Surgery, Barmherzige Brüder Hospital Regensburg, Germany
| | - Markus Steinbauer
- Department of Vascular Surgery, Barmherzige Brüder Hospital Regensburg, Germany
| | - Christian Uhl
- Department of Vascular Surgery, Barmherzige Brüder Hospital Regensburg, Germany
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Martin R, Vanesa G DC, Raleigh JV, Jose C, Vadim K, Maynar M, Zander T. Common Femoral Artery Stenting: Computed Tomography Angiography Based Long-Term Patency. Vasc Endovascular Surg 2021; 55:571-576. [PMID: 33906555 DOI: 10.1177/15385744211010447] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite considerable morbid-mortality rates, common femoral endarterectomy is still considered the gold standard for atherosclerotic common femoral artery (CFA) disease. The aim of this study was to demonstrate computed tomography angiography based long-term patency after CFA stent placement and to analyze associated risk factors for restenosis. METHODS A retrospective and observational study was carried out in consecutive patients treated with endovascular stent placement in CFA lesions. A clinical follow-up and imaging study was performed using MD-CTA to assess different degrees of in stent restenosis (ISR) and primary, assisted, and secondary patency rates. RESULTS In a 5-year period, 35 extremities were treated in 33 patients with self-expandable nitinol stents. The technical success was 100% without complications related to the procedure. The mean follow-up (FU) was 32.2 months, and 8 limbs were lost. The degree of CFA stenosis was reduced from 79.69 ± 26.47% to 11.23 ± 24.53%. ISR < 20%, 20-70%, and ≥ 70% was evident in 15 (55.6%), 9 (33.3%), and 3 (11.1%) limbs, respectively. Estimated primary, assisted, and secondary patency was 79.5, 96.3, and 96.3%, respectively, after 24 months and 79.5, 96.3, and 96.3%, respectively after 60 months, with a freedom of clinical driven target lesion revascularisation rate of 87.8%. CONCLUSION Endovascular treatment with self-expandable nitinol stents in CFA lesions had a high technical success rate and was related to few complications. A mild form of intimal hyperplasia was observed in a considerable number of cases. However, long-term patency was high; therefore, CFA stent placement might be a suitable therapeutic alternative in selected patients.
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Affiliation(s)
- Rabellino Martin
- Department of Angiography and Endovascular Therapy, 37533Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Di Caro Vanesa G
- Department of Angiography and Endovascular Therapy, 37533Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Juan Valle Raleigh
- Department of Angiography and Endovascular Therapy, 37533Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Chas Jose
- Department of Vascular Surgery, 37533Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Kotowicz Vadim
- Department of Vascular Surgery, 37533Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Manuel Maynar
- Department of Endovascular Therapy, 37533Hospiten Hospital Group, Santa Cruz de Tenerife, Canary Island, Spain.,University of Las Palmas de Gran Canarias (ULPGC), Las Palmas, Canary Island, Spain
| | - Tobias Zander
- Department of Endovascular Therapy, 37533Hospiten Hospital Group, Santa Cruz de Tenerife, Canary Island, Spain
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Hassan AE, Nakao M, Katsumata H, Inagaki Y, Tanaka K, Otsuki H, Arashi H, Yamaguchi J, Hagiwara N. Clinical outcomes after balloon angioplasty with Crosser device for heavily calcified common femoral and popliteal artery disease. Heart Vessels 2021; 36:1359-1365. [PMID: 33635347 DOI: 10.1007/s00380-021-01816-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/19/2021] [Indexed: 11/24/2022]
Abstract
Data on the mid-term clinical outcomes after endovascular treatment (EVT) using a Crosser catheter (C. R. Bard, Inc.) as a crossing or flossing device for a heavily calcified lesion in the common femoral artery (CFA) or popliteal artery (PA) are lacking. The aim of this study was to investigate the safety and efficacy of EVT using a Crosser catheter for isolated and heavily calcified CFA or PA disease. We retrospectively analyzed 64 consecutive patients (72 lesions; CFA 30, PA 42) who underwent EVT for heavily calcified CFA or PA lesions with Crosser catheters between April 2015 and April 2019. The primary endpoint was clinically driven target lesion revascularization (CD-TLR). The median follow-up was 18.5 months. The mean age of the study population was 70 ± 9.5 years, with a male prevalence of 73.6%. The mean Proposed Peripheral Artery Calcification Scoring System grade was 2.9 ± 0.9. Procedure success, defined as 50% or less residual stenosis without suboptimal results, was achieved in 94.4% of lesions. There were no cases of bailout stenting or target lesion-related complications. After EVT, the 1-year CD-TLR-free rate for CFA and PA lesions was 87.4 and 76.8%, respectively. The corresponding rates at 2 years were 82.2 and 62.8%, respectively. In the multivariate analysis used to define CD-TLR predictors for CFA and PA lesions, hemodialysis was the only independent predictor (HR 3.35, 95% CI 1.02-13.95, P = 0.045). EVT with a Crosser device for heavily calcified CFA and PA lesions seems to be safe and feasible.
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Affiliation(s)
- Ahmed Elsayed Hassan
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masashi Nakao
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Haruka Katsumata
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yusuke Inagaki
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kazuki Tanaka
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Hisao Otsuki
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Hiroyuki Arashi
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Junichi Yamaguchi
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Nobuhisa Hagiwara
- Department of Cardiology, The Heart Institute of Japan, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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Allen KB, Adams JD, Badylak SF, Garrett HE, Mouawad NJ, Oweida SW, Parikshak M, Sultan PK. Extracellular Matrix Patches for Endarterectomy Repair. Front Cardiovasc Med 2021; 8:631750. [PMID: 33644135 PMCID: PMC7904872 DOI: 10.3389/fcvm.2021.631750] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/25/2021] [Indexed: 12/15/2022] Open
Abstract
Patch repair is the preferred method for arteriotomy closure following femoral or carotid endarterectomy. Choosing among available patch options remains a clinical challenge, as current evidence suggests roughly comparable outcomes between autologous grafts and synthetic and biologic materials. Biologic patches have potential advantages over other materials, including reduced risk for infection, mitigation of an excessive foreign body response, and the potential to remodel into healthy, vascularized tissue. Here we review the use of decellularized extracellular matrix (ECM) for cardiovascular applications, particularly endarterectomy repair, and the capacity of these materials to remodel into native, site-appropriate tissues. Also presented are data from two post-market observational studies of patients undergoing iliofemoral and carotid endarterectomy patch repair as well as one histologic case report in a challenging iliofemoral endarterectomy repair, all with the use of small intestine submucosa (SIS)-ECM. In alignment with previously reported studies, high patency was maintained, and adverse event rates were comparable to previously reported rates of patch angioplasty. Histologic analysis from one case identified constructive remodeling of the SIS-ECM, consistent with the histologic characteristics of the endarterectomized vessel. These clinical and histologic results align with the biologic potential described in the academic ECM literature. To our knowledge, this is the first histologic demonstration of SIS-ECM remodeling into site-appropriate vascular tissues following endarterectomy. Together, these findings support the safety and efficacy of SIS-ECM for patch repair of femoral and carotid arteriotomy.
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Affiliation(s)
- Keith B Allen
- St. Luke's Hospital of Kansas City, St. Luke's Mid America Heart Institute, Kansas City, MO, United States
| | - Joshua D Adams
- Carilion Clinic Aortic and Endovascular Surgery, Roanoke, VA, United States
| | - Stephen F Badylak
- Department of Bioengineering, Department of Surgery, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - H Edward Garrett
- Cardiovascular Surgery Clinic, University of Tennessee, Memphis, Memphis, TN, United States
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Peters AS, Meisenbacher K, Weber D, Bisdas T, Torsello G, Böckler D, Bischoff MS. Isolated femoral artery revascularisation with or without iliac inflow improvement - a less invasive surgical option in critical limb ischemia. VASA 2021; 50:217-223. [PMID: 33435742 DOI: 10.1024/0301-1526/a000934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Isolated femoral artery revascularisation (iFAR) represents a well-established surgical method in the treatment of peripheral arterial disease (PAD) involving common femoral artery disease. Data for iFAR in multilevel PAD are inconsistent, particularly in patients with critical limb ischemia (CLI). The aim of the study was to evaluate the outcome of iFAR in CLI regarding major amputation and reintervention and to identify associated risk factors for this outcome. Patients and methods: The data used have been derived from the German Registry of Firstline Treatment in Critical Limb Ischemia (CRITISCH). A total of 1200 patients were enrolled in 27 vascular centres. This sub-analysis included patients, which were treated with iFAR with/without concomitant iliac intervention. For detection of risk factors for the combined endpoint of major amputation and/or reintervention, selection of variables for multiple regression was conducted using stepwise forward/backward selection by Akaike's information criterion. Results: 95 patients were included (mean age: 72 years ± 10.82; 64.2% male). Of those, 32 (33.7%) participants reached the combined endpoint. Risk factor analysis revealed continued tobacco use (odds ratio [OR] 2.316, confidence interval [CI] 0.832-6.674), TASC D-lesion (OR: 2.293, CI: 0.869-6.261) and previous vascular intervention in the trial leg (OR: 2.720, CI: 1.037-7.381) to be associated with reaching the combined endpoint. Conclusions: iFAR provides a reasonable, surgical option to treat CLI. Lesion length (TASC D) seems to have a negative impact on outcome. Further research is required to better define the future role of iFAR for combined femoro-popliteal lesions in CLI - best in terms of a randomised controlled trial.
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Affiliation(s)
- Andreas S Peters
- Department of Vascular and Endovascular Surgery Heidelberg, University Hospital Heidelberg, Germany
| | - Katrin Meisenbacher
- Department of Vascular and Endovascular Surgery Heidelberg, University Hospital Heidelberg, Germany
| | - Dorothea Weber
- Institute of Medical Biometry and Informatics, University of Heidelberg, Germany
| | - Theodosios Bisdas
- Department of Vascular Surgery, St. Franziskus Hospital Münster GmbH, Münster, Germany
| | - Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus Hospital Münster GmbH, Münster, Germany
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery Heidelberg, University Hospital Heidelberg, Germany
| | - Moritz S Bischoff
- Department of Vascular and Endovascular Surgery Heidelberg, University Hospital Heidelberg, Germany
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Serna Santos J, Söderström M, Helminen R, Aho P, Halmesmäki K, Venermo M. Outcome after Hybrid Outflow Interventions for Chronic Limb-threatening Ischemia. Scand J Surg 2020; 110:241-247. [PMID: 33308022 DOI: 10.1177/1457496920975608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Because chronic limb-threatening ischemia (CLTI) is often associated with multilevel arterial disease, it usually requires revascularization at different sites of the limb vasculature. We aim to assess the outcome of the hybrid interventions including open surgical revascularization together with outflow segment percutaneous transluminal angioplasty (PTA) in patients with chronic limb-threatening ischemia. MATERIAL AND METHODS This study included all hybrid outflow-PTA interventions (n = 80) on patients suffering from CLTI performed in Helsinki University Hospital between 2003 and 2015. Follow-up ended on 31 December 2019. Patient data were prospectively collected into our vascular registry and scrutinized retrospectively. Thirty-one patients (39%) suffered from rest pain (Rutherford category IV) and 49 patients (61%) had ischemic ulcers (Rutherford category V-VI). The most common open surgical procedure was femoral endarterectomy (n = 63, 79%) and the most common endovascular procedure was superficial femoral artery percutaneous transluminal angioplasty (n = 65, 81%). Mean follow-up time was 56 months (range: 4 days-183 months). RESULTS Limb salvage was at 30 days-92%, at 1 year-91%, and at 5 and 10 years-86%. Survival and amputation-free survival were at 30 days-93% and 86%, at 1 year-80% and 76%, at 5 years-51% and 48%, and at 10 years-21% and 21%. Wound healing at 3, 6, and 12 months was 48%, 71%, and 87%. Freedom from target lesion revascularization was at 30 days-97%, at 1 year-88%, at 5 years-72%, and at 10 years-66%. CONCLUSION Hybrid outflow revascularization is an important tool in the vascular surgeon's armamentarium for treatment of patients with multilevel arterial disease causing chronic limb-threatening ischemia.
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Affiliation(s)
- J Serna Santos
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland
| | - M Söderström
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland
| | - R Helminen
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland
| | - P Aho
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland
| | - K Halmesmäki
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland
| | - M Venermo
- Department of Vascular Surgery, Helsinki University Hospital, Helsinki, Finland
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DeCarlo C, Boitano LT, Sumpio B, Latz CA, Feldman Z, Pendleton AA, Chou EL, Stern JR, Dua A. Comparative Analysis of Outcomes in Patients Undergoing Femoral Endarterectomy plus Endovascular (Hybrid) or Bypass for Femoropopliteal Occlusive Disease. Ann Vasc Surg 2020; 72:227-236. [PMID: 32927041 DOI: 10.1016/j.avsg.2020.08.143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/10/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION The gold-standard for management of combined common femoral artery (CFA) and superficial femoral artery (SFA) atherosclerotic occlusive disease has traditionally been open femoral endarterectomy and femoral-popliteal bypass. Hybrid approaches involving an open and endovascular component are increasingly common. The aim of this study was to compare perioperative outcomes in patients who underwent an open versus hybrid revascularization. METHODS NSQIP data, years 2012-2017, were queried for patients who underwent nonemergent CFA endarterectomy with either SFA transluminal intervention or bypass. The primary outcome of interest was a composite of cardiovascular, pulmonary, and renal complications (systemic) and mortality. Two propensity-weight adjusted analyses were performed: 1) comparing hybrid and prosthetic bypass 2) comparing hybrid and vein bypass. RESULTS There were 4,478 patients included (1,537 hybrid, 1,408 prosthetic, 1,533 vein); 64.8% were men, and the mean age was 67.8 ± 9.7 years; 29.9% had claudication, 38.8% had tissue loss, and 31.3 were unspecified. In the propensity-weighted analysis comparing hybrid to prosthetic bypass, there was no difference in systemic complications (OR = 1.29 for prosthetic vs. hybrid; 95% CI: 0.95-1.76; P = 0.107) or mortality (OR = 1.54; 95% CI: 0.71-3.33; P = 0.275). Prosthetic bypass was associated with more deep surgical-site infections (OR = 2.02; 95% CI: 1.19-3.45; P = 0.010), postoperative sepsis (OR = 2.07; 95% CI: 1.13-3.76; P = 0.018), unplanned 30-day readmission (OR = 1.28; 95% CI: 1.04-1.58; P = 0.021), and the composite of any complication (OR = 1.38; 95% CI: 1.18-1.61; P < 0.001). In the propensity-weighted analysis comparing hybrid to vein bypass, there was no difference in systemic complications (OR = 1.10 for vein vs. hybrid; 95% CI: 0.81-1.49; P = 0.552) or mortality (OR = 0.91; 95% CI: 0.42-2.00; P = 0.819). Vein bypass was associated with more superficial surgical-site infections (OR = 1.45; 95% CI: 1.04-2.02; P = 0.028), and the composite of any complication (OR = 1.32; 95% CI: 1.13-1.54; P = 0.001). Overall mortality was significantly higher patients with systemic complications (13.9% vs 0.1%; P < 0.001). Systemic complications were less common in patients with claudication undergoing hybrid revascularization than vein or prosthetic bypass. CONCLUSIONS Claudicants undergoing bypass experienced more systemic complications than those undergoing hybrid procedures, but there appears to be no increased risk of systemic complications or mortality with open reconstruction when compared to hybrid procedures for other indications. Other complications, such as infection, postoperative transfusion, and readmission, were more common in the bypass groups.
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Affiliation(s)
- Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Laura T Boitano
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Brandon Sumpio
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christopher A Latz
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Zach Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Anna A Pendleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Elizabeth L Chou
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jordan R Stern
- Division of Vascular Surgery, Department of Surgery, Stanford Hospital, Palo Alto, CA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Esposito A, Menna D, Baiano A, Benedetto P, Di Leo F, Cappiello AP. Eversion Endarterectomy of the Femoral Bifurcation: Technique, Results and Potential Advantages. Ann Vasc Surg 2020; 66:580-585. [DOI: 10.1016/j.avsg.2019.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 11/29/2019] [Accepted: 12/01/2019] [Indexed: 11/15/2022]
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Miyake K, Nakamura T, Fujimura H, Shibuya T, Sawa Y. Efficacy of the Decalcification of Heavily Calcified Femoral Bifurcation Lesions Using a Cavitron Ultrasonic Surgical Aspirator. Ann Vasc Surg 2020; 69:274-284. [PMID: 32479872 DOI: 10.1016/j.avsg.2020.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/05/2020] [Accepted: 05/08/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND In the current diabetes era, severe calcified femoral bifurcation lesions extending to the external elastic lamina are sometimes experienced and are technically challenging during conventional endarterectomy. We previously reported an alternative method, a decalcification technique with a Cavitron Ultrasonic Surgical Aspirator (CUSA), for calcified lesions. This study aimed to clarify the efficacy of CUSA decalcification technique. METHODS A total of 26 limbs treated with CUSA decalcification from 2014 to 2017 were enrolled and evaluated hemodynamically with ankle-brachial index (ABI) and morphologically with computed tomography angiography (CTA). ABI was measured every 6 months, and CTA was performed early after surgery and then annually thereafter. Curved planar reformation images and cross-sectional multiplanar reconstruction images obtained by CTA were used to measure the cross-sectional area of the common femoral artery (CFA). Then, the time courses of the ABI and CFA areas were analyzed. RESULTS The operative indication was claudication in 80.8%, rest pain in 7.7%, and tissue loss in 11.5% of the cases. A concomitant profundaplasty was performed in 34.6% of the cases. One case of an intraoperative arterial wall perforation was experienced as a procedure-related complication. Hemodynamic success rate was 96.2% (preoperative ABI: 0.37 ± 0.28, postoperative ABI: 0.75 ± 0.15, P < 0.0001) and technical success rate was 100.0% (preoperative CFA area: 4.1 ± 5.9 mm2, postoperative CFA area: 46.1 ± 17.0 mm2, P < 0.0001), with clinical improvement achieved in 95.8% of cases. Primary and secondary patency rates of the CFA were 100.0% at 2 years postoperatively, and the reintervention-free rate for the ipsilateral limb was 88.5% at 2 years postoperatively. Over a median follow-up period of 28.0 months (range, 12.3-67.0 months), the restenosis rate of CFA was 7.6%, when restenosis was defined as a >50% decrease in cross-sectional area. CONCLUSIONS CUSA decalcification is a safe and effective alternative method to treat heavily calcified femoral lesions with a good patency rate and a low restenosis rate.
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Affiliation(s)
- Keisuke Miyake
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan; Department of Vascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Takashi Nakamura
- Department of Vascular Surgery, Japan Organization of Occupational Health and Safety, Osaka Rosai Hospital, Sakai, Osaka, Japan.
| | - Hironobu Fujimura
- Department of Cardiovascular Surgery, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Takashi Shibuya
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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McMackin KK, Ghobrial G, Fadoul MA, Lombardi JV. Herpes wound infection after femoral endarterectomy. JOURNAL OF VASCULAR SURGERY CASES INNOVATIONS AND TECHNIQUES 2020; 6:185-187. [PMID: 32322772 PMCID: PMC7160525 DOI: 10.1016/j.jvscit.2020.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/30/2020] [Indexed: 11/23/2022]
Abstract
Wound infection after common femoral endarterectomy is a well-documented phenomenon leading to significant morbidity, especially in the setting of a prosthetic graft. A push has recently been made in the literature for salvage of the prosthetic graft using debridement, antibiotics, and vacuum-assisted closure therapy. Herein we present the case of wound infection after common femoral endarterectomy with bovine patch angioplasty initially presumed to be of bacterial origin that failed to respond to vacuum-assisted closure therapy until the viral nature of the pathogen was discovered. The patient will continue lifelong valacyclovir for suppressive therapy.
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Affiliation(s)
| | - Gaby Ghobrial
- Division of Vascular Surgery, Cooper University Hospital, Camden, NJ
| | - Mikael A Fadoul
- Division of Vascular Surgery, Cooper University Hospital, Camden, NJ
| | - Joseph V Lombardi
- Division of Vascular Surgery, Cooper University Hospital, Camden, NJ
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Device Selection in Femoral-Popliteal Arterial Interventions. Interv Cardiol Clin 2020; 9:197-206. [PMID: 32147120 DOI: 10.1016/j.iccl.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Endovascular intervention devices for femoral-popliteal arterial disease have evolved in the last decade to more effectively treat patients with symptoms of claudication, improve tissue healing, and prevent amputation in patients with critical limb ischemia. Drug-eluting stents and drug-coated balloon therapies have demonstrated significant improvements in short- and mid-term patency and decreases in future target vessel interventions over uncoated balloon angioplasty. Adjunctive lesion preparation options including atherectomy devices are available to treat more complex and calcified lesions, but comparative data are still required.
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Uhl C, Götzke H, Zeman F, Woronowicz S, Betz T, Töpel I, Steinbauer M. Long-Term Outcome of Common Femoral Artery Endarterectomy In Octogenarians and Non-Octogenarians. Scand J Surg 2020; 110:400-406. [PMID: 32098583 DOI: 10.1177/1457496920907733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Arteriosclerotic disease of the common femoral artery can be treated by surgical or endovascular intervention. Elderly patients are said to have a worse outcome if treated by surgical means; however, data to support this theory are missing. METHODS Retrospective analysis of all patients who underwent common femoral artery endarterectomy between March 2007 and July 2018 in our clinic. Group 1 included all patients <80 years and Group 2 included all patients ⩾80 years. Endpoints were patency rates, limb salvage, and overall survival. RESULTS During this time period, 977 common femoral artery endarterectomies were performed. Indication was claudication in 61.5% and critical limb ischemia in 38.5%. Group 1 included 805 cases (82.4%) and Group 2 included 172 cases (17.6%). Thirty-day mortality was 2.7% (Group 1 = 1.6% versus Group 2 = 7.6%; p < 0.001) and 30-day major amputation was 1.1% (Group 1 = 0.7% versus Group 2 = 2.9%; p = .043). Primary patency and secondary patency were 84.2% and 96.8%, respectively, after 7 years. Limb salvage (93.7%, Group 1 = 94.1% versus Group 2 = 91.8%; p = .088) and overall survival (52.0%, Group 1 = 59.1% versus Group 2 = 15.7%; p = .006) were significantly different after the same time period. Multivariable analysis showed female gender to be a risk factor for loss of primary patency. Age ⩾ 80 years and ulcer or gangrene were risk factors for death. Statin use was beneficial to survival. CONCLUSIONS Common femoral artery endarterectomy is a safe procedure with excellent long-term results. Octogenarians have an increased risk for perioperative mortality and major amputation.
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Affiliation(s)
- Christian Uhl
- Clinic of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Pruefeningerstrasse 81, Regensburg, 93049, Germany
| | - Hannah Götzke
- Clinic of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, University of Regensburg, Regensburg, Germany
| | - Sandra Woronowicz
- Clinic of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Thomas Betz
- Clinic of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Ingolf Töpel
- Clinic of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Markus Steinbauer
- Clinic of Vascular Surgery, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
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Wee I, Tan G, Ng S, Chan ESY, Ng JJ, Samuel M, Choong AMTL. Endovascular versus open surgical endarterectomy for atherosclerotic lesions of the common femoral artery (CFA). Hippokratia 2020. [DOI: 10.1002/14651858.cd013545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ian Wee
- Yong Loo Lin School of Medicine, National University of Singapore; Singapore Singapore
| | - Gerald Tan
- Newcastle University Medicine Malaysia (NUMed Malaysia); Johor Malaysia
| | - Sheryl Ng
- Cardiovascular Research Institute, National University of Singapore; Singapore Singapore
| | | | - Jun Jie Ng
- Cardiovascular Research Institute, National University of Singapore; Singapore Singapore
- SingVaSC, Singapore Vascular Surgical Collaborative; Singapore Singapore
- Yong Loo Lin School of Medicine, National University of Singapore; Department of Surgery; Singapore Singapore
- National University Heart Centre; Division of Vascular Surgery; Singapore Singapore
| | - Miny Samuel
- NUS Yong Loo Lin School of Medicine; Research Support Unit; NUHS Tower Block, Level 11 1E Kent Ridge Road Singapore Singapore 119228
| | - Andrew MTL Choong
- Cardiovascular Research Institute, National University of Singapore; Singapore Singapore
- SingVaSC, Singapore Vascular Surgical Collaborative; Singapore Singapore
- Yong Loo Lin School of Medicine, National University of Singapore; Department of Surgery; Singapore Singapore
- National University Heart Centre; Division of Vascular Surgery; Singapore Singapore
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Soares TR, Amorim P, Manuel V, Lopes A, Fernandes E Fernandes R, Martins C, Pedro LM. A single-center experience in the eversion femoral endarterectomy. Vascular 2020; 28:348-354. [PMID: 32041491 DOI: 10.1177/1708538120905440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Endarterectomy is the treatment of choice for arterial occlusive disease of the femoral bifurcation. Longitudinal arteriotomy and prosthetic patch angioplasty is the standard technique but, due to the increasing concerns with prosthetic-related infections and multidrug-resistant pathogens our group adopted an alternative approach. We present our experience with eversion femoral endarterectomy. METHODS All patients submitted to eversion femoral endarterectomy in a single institution during 2016-2019 were retrospectively analyzed. Patient demographics, surgical data, and complications were captured from medical records. RESULTS Nineteen patients, 84.2% male and a median age of 67 years (IQR 62-78) were submitted to eversion femoral endarterectomy with a median follow-up of 180 days (IQR 71-395). Seventeen (89.4%) patients were treated for chronic limb ischemia and the other two were submitted to femoral endarterectomy during endovascular aortic aneurysm repair. Most of the patients had smoking history (84.2%), followed by hypertension (68.4%), dyslipidemia (63.2%), coronary heart disease (29.4%), and diabetes (26.3%). Only 3 patients (15.8%) were submitted exclusively to endarterectomy, 13 (68.4%) were submitted to endarterectomy as an adjuvant for peripheral endovascular treatment, 2 (10.5%) as a concomitant procedure to endovascular repair of aortic aneurysm, and 1 (5.3%) was complemented with thrombectomy of the femoro-popliteal sector. Primary patency rates were 100% and 87.5% (CI (38.7-98.1)) at 6 and 12 months, respectively. Primary-assisted and secondary patency rates were 100%. The 30-day mortality rate was 5.3% (n = 1) and complication rate 10.5% (n = 2). One patient complicated with acute renal disease related to rhabdomyolysis. Another patient developed a wound-related hematoma treated with surgical drainage, but died three days after consequent to ischemia-reperfusion injury. CONCLUSIONS Eversion femoral endarterectomy is a safe and feasible technique, with good patency results and respecting the concept of leaving nothing behind. A careful control of the proximal and distal endpoints is essential for the success of the technique.
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Affiliation(s)
- Tony R Soares
- Vascular Surgery Service, Heart and Vessels Department, Hospital Santa Maria (CHULN), Lisbon, Portugal.,Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Pedro Amorim
- Vascular Surgery Service, Heart and Vessels Department, Hospital Santa Maria (CHULN), Lisbon, Portugal.,Lisbon Academic Medical Centre, Lisbon, Portugal.,Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Viviana Manuel
- Vascular Surgery Service, Heart and Vessels Department, Hospital Santa Maria (CHULN), Lisbon, Portugal.,Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Alice Lopes
- Vascular Surgery Service, Heart and Vessels Department, Hospital Santa Maria (CHULN), Lisbon, Portugal.,Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Ruy Fernandes E Fernandes
- Vascular Surgery Service, Heart and Vessels Department, Hospital Santa Maria (CHULN), Lisbon, Portugal.,Lisbon Academic Medical Centre, Lisbon, Portugal.,Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Carlos Martins
- Vascular Surgery Service, Heart and Vessels Department, Hospital Santa Maria (CHULN), Lisbon, Portugal.,Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Luís Mendes Pedro
- Vascular Surgery Service, Heart and Vessels Department, Hospital Santa Maria (CHULN), Lisbon, Portugal.,Lisbon Academic Medical Centre, Lisbon, Portugal.,Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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Stricker H, Spinedi L, Limoni C, Giovannacci L. Stent-Assisted Angioplasty (SAA) at the Level of the Common Femoral Artery Bifurcation: Long-Term Outcomes. Cardiovasc Intervent Radiol 2020; 43:541-546. [PMID: 31974742 PMCID: PMC7060158 DOI: 10.1007/s00270-020-02413-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 01/08/2020] [Indexed: 12/24/2022]
Abstract
Background The objective of this retrospective single-center study was to report the initial and the long-term outcome after stent-assisted angioplasty of occlusive disease at the common femoral artery. Materials and Methods Between 1995 and 2015, 94 limbs in 79 consecutive patients (54 men; mean age 70 ± 8.6 years) underwent angioplasty with self-expanding stent implantation in 94 common femoral arteries. Critical limb ischemia was present in 15 limbs (16%); the other patients had claudication. Results Technical success was 99%. Complications occurred in 5/94 interventions (5.3%): puncture site hematomas (2), arteriovenous fistula (1), cholesterol embolism (1), and dissection of the access site artery (1). The intervention was outpatient-based in 98%. Median follow-up was 53 months. Ankle–brachial index (ABI) rose from 0.71 ± 0.17 to 1.0 ± 0.2 (p < .001) immediately after the intervention and was 1.03 ± 0.2 after 1 year and 0.96 ± 0.21 at the last follow-up visit (p < .001 compared to pre-interventional ABI). During follow-up, restenosis was found in 23/94 limbs (25%); 15 limbs were treated by angioplasty, 3 by surgery, and 5 conservatively. One limb was amputated below the knee 6 months after stent-assisted angioplasty (SAA). Death rate during follow-up was 35/79 patients (44%). Conclusions SAA of the CFA resulted in high immediate success and a low complication rate. Restenosis rate was moderate, and target lesions could easily be retreated by angioplasty. The main hazard was not restenosis, but death during follow-up.
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Affiliation(s)
- H Stricker
- Department of Vascular Medicine, Ospedale La Carità, Locarno, Switzerland. .,Department of Angiology, Ospedale La Carità, via all'Ospedale 1, 6600, Locarno, Switzerland.
| | - L Spinedi
- Department of Vascular Medicine, Ospedale La Carità, Locarno, Switzerland
| | - C Limoni
- University of Applied Sciences and Arts of Southern Switzerland, Lugano, Switzerland
| | - L Giovannacci
- Department of Vascular Surgery, Ospedale Civico, Lugano, Switzerland
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A Hybrid Technique to Treat Iliofemoral Lesions Using a Covered Stent Associated with Open Femoral Repair. Ann Vasc Surg 2019; 66:601-608. [PMID: 31866550 DOI: 10.1016/j.avsg.2019.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 11/28/2019] [Accepted: 12/01/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND To describe a hybrid approach for complex iliofemoral lesions and report short-term and mid-term results. METHODS In this single-center retrospective study, all consecutive patients (n = 32, 36 limbs) who underwent hybrid repair of complex iliofemoral lesions between 2012 and 2017 using a conformable self-expandable covered stent for external iliac artery lesions and open repair of the common femoral artery were included. Lesions were responsible for claudication in 13 (36%) limbs, rest pain in 13 (36%) limbs and tissue loss in 10 (28%) limbs. Over a wire crossing the iliac lesion, the covered stent was deployed, externalized through the femoral arteriotomy, and cut at the iliofemoral junction in such a way that no untreated transition zone remained between the stent and the open reconstruction of the femoral artery. RESULTS Two elderly patients with critical limb ischemia died during the postoperative course, giving in-hospital mortality of 6.2%. Four (12.5%) presented with moderate to severe complications, including one transtibial amputation in a patient who presented with tissue loss at admission. The median follow-up period was 24.1 months (range: 0.8-64 months). One-year and two-year Kaplan-Meier estimates of overall survival were 91% (95% CI: 97-74) and 76% (95% CI: 89-53). One-year and two-year estimates of freedom from major amputation were 96% (95% CI: 99-76) and 91% (95% CI: 97-66). Estimates of primary patency, assisted primary patency, and secondary patency were: 93.7 (95% CI: 77.1-98.4) at 1 year, and 93.7 (95% CI: 77.1-98.4) at 2 years; 96.7% (95% CI: 78.6-99.6) at 1 year, and 96.7% (95% CI: 78.6-99.6) at 2 years; 96.7% (95% CI: 78.6-99.6) at 1 year and 96.7% (95% CI: 78.6-99.6) at 2 years, respectively. CONCLUSIONS Our hybrid approach for iliofemoral lesions provided acceptable mortality and good mid-term patency rates. Further studies with long-term followup are needed to evaluate the safety and durability of this technique.
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Treatment of lymphocele with negative pressure wound therapy post inguinal mass excision: A case-report. Int J Surg Case Rep 2019; 66:43-47. [PMID: 31790951 PMCID: PMC6909207 DOI: 10.1016/j.ijscr.2019.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/01/2019] [Accepted: 11/07/2019] [Indexed: 12/04/2022] Open
Abstract
Safe and effective approach for treating inguinal lymphocele. Excision with ligation of lymphatic vessels. Negative pressure wound therapy.
Introduction A lymphocele is defined as an atypical collection of lymphatic fluid not bordered by distinct epithelial lining, which develops in anatomic compartments. Inguinal lymphocele is a common complication of surgery in the inguinal region, with an incidence ranging from 1 to 87 %. This report summarizes the management of an inguinal lymphocele post excision of an inguinal mass. Presentation of case Herein, we present a case in which an inguinal lymphocele developed four months post excision of an inguinal mass, which was later diagnosed as lymphoma and treated with iliac chain radiation therapy. The conservative treatment with lymphocele drainage, compression dressing and prophylactic antibiotic was initially implemented. As the patient did not respond to conservative treatment, the surgical strategy consisted of excision of lymphocele associated with lymphatic ducts ligation. Negative pressure wound therapy completed the treatment. Discussion Non-surgical treatment of lymphocele developing from lymphatic injure during groin dissection is not rarely unsuccessful. Surgical options include lymphocele excision with either ligation of the lymphatic ducts or lymphatic-venous shunts between afferent lymphatics and the collateral branch of great saphenous vein. Vacuum-assisted closure therapy assists the wound healing process by increasing blood flow, removing inhibiting factors of wound healing and decreasing the bacterial count. Conclusion Inguinal lymphocele that is not reabsorbed or does not resolve with conservative treatment should be surgically treated. Lymphocele excision with ligation of lymphatic vessels, followed by negative pressure wound therapy appears to be a safe and effective approach.
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 721] [Impact Index Per Article: 144.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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