1
|
Juneja A, Garuthara M, Talathi S, Rao A, Landis G, Etkin Y. Predictors of poor outcomes after lower extremity revascularization for acute limb ischemia. Vascular 2024; 32:632-639. [PMID: 36696536 DOI: 10.1177/17085381231154290] [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: 01/26/2023]
Abstract
OBJECTIVES Acute lower extremity ischemia is one of the most common emergencies in vascular surgery and is a cause of considerable morbidity and mortality. The goal of this study was to evaluate outcomes of revascularization for acute lower extremity ischemia and to determine factors associated with perioperative morbidity and mortality. METHODS A total of 354 patients underwent urgent revascularization for acute lower extremity ischemia at an academic medical center between 2014 and 2019. A retrospective review of patients' demographics, comorbidities, etiology and severity of limb ischemia, and procedural characteristics was recorded. Outcomes, including postoperative complications, perioperative limb loss, and mortality, were analyzed. RESULTS The mean patient age was 69 ± 17 years, and 52% were females. 50% of patients presented with Rutherford Class IIb ischemia. Arterial embolization was the most common cause of limb ischemia, seen in 33% of cases. Open surgical revascularization was performed in 241 (68%) patients, while endovascular and hybrid approaches were utilized in 53 (15%) and 60 (17%) cases, respectively. Postoperative adverse events occurred in 44% of patients, including wound complications (11%), cardiac (5%) and pulmonary (16%) complications, strokes (4%), UTIs (10%), renal failure (14%), bleeding (5%), and compartment syndrome (3%). The rate of unplanned return to the operating room was 21%. Major adverse cardiovascular events were seen in 103 (29%) patients and major adverse limb events were seen in 57 (16%) patients. The median length of stay was 10 days (IQR = 4); 49% patients were discharged to skilled nursing facility and 19% were readmitted within 30 days.The rate of amputation during index admission was 10%, and perioperative mortality was 20%. Gender, tibial runoff, and etiology of limb ischemia were independent predictors of limb loss. Women had lower risk of limb loss than men (OR, 0.11; 95% CI, 0.023, 0.38). Poor tibial runoff (one-vessel or absence of flow below the knee) was a significant predictor of limb loss as compared to three-vessel runoff (OR, 14.92; 95% CI, 1.92, 115.88). Aneurysmal disease (OR, 38.35; 95% CI, 3.54, 42.45) and traumatic injuries (OR, 108.08; 95% CI, 8.21, 159.06) were the strongest predictors of amputation as compared to other etiologies of limb ischemia. Multivariate model identified ESRD (OR, 9.2; 95% CI, 1.8-46.3), degree of ischemia (class IIb or higher vs class IIa; OR, 3.5; 95% CI, 1.2-10.6), and age (OR, 1.5; 95% CI 1.1-2.0 for every 10 years) as independent predictors of perioperative mortality. CONCLUSIONS Urgent revascularization for management of acute limb ischemia is associated with high morbidity and mortality. Elderly patients with ESRD presenting with severely threatened limbs have especially high risk of perioperative mortality and may not be ideal candidates for limb salvage.
Collapse
Affiliation(s)
- Amandeep Juneja
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Melissa Garuthara
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Sonia Talathi
- Division of Vascular and Endovascular Surgery, Montefiore Medical Center, Bronx, NY, USA
| | - Amit Rao
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Gregg Landis
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Yana Etkin
- Department of Surgery, Division of Vascular and Endovascular Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| |
Collapse
|
2
|
Csavajda A, Toth K, Kovacs N, Rona S, Vamosi Z, Berta B, Kulcsar FZ, Bertrand OF, Hizoh I, Ruzsa Z. The Clinical Impact of Access Site Selection for Successful Thrombolysis and Intervention in Acute Critical Lower Limb Ischaemia (RAD-ALI Registry). Life (Basel) 2024; 14:666. [PMID: 38929649 PMCID: PMC11205031 DOI: 10.3390/life14060666] [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: 04/14/2024] [Revised: 04/30/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Acute limb ischaemia (ALI) is of great clinical importance due to its consequent serious complications and high comorbidity and mortality rates. The purpose of this study was to compare the acute success and complication rates of CDT performed via transradial, transbrachial, and transfemoral access sites in patients with acute lower limb vascular occlusion and to investigate the 1-year outcomes of CDT and MT for ALI. Methods: Between 2008 and 2019, 84 consecutive patients with ALI were treated with CDT in a large community hospital. Data were collected and retrospectively analysed. The primary ("safety") endpoints encompassed major adverse events (MAEs), major adverse limb events (MALEs), and the occurrence of complications related to the access site. Secondary ("efficacy") endpoints included both technical and clinical achievements, treatment success, fluoroscopy time, radiation dose, procedure time, and the crossover rate to an alternative puncture site. Results: CDT was started with radial (n = 17), brachial (n = 9), or femoral (n = 58) access. CDT was technically successful in 74/84 patients (88%), but additional MT and angioplasty and/or stent implantation was necessary in 17 (20.2%) and 45 cases (53.6%), respectively. Clinical success was achieved in 74/84 cases (88%). The mortality rate at 1 year was 14.3%. The cumulative incidence of MAEs and MALEs at 12 months was 50% and 40.5%, respectively. After conducting multivariate analysis, history of Rutherford stage IIB (hazard ratio [HR], 3.64; 95% confidence interval [CI], 1.58-8.41; p = 0.0025), occlusion of the external iliac artery (HR, 27.52; 95% CI, 2.83-267.33; p = 0.0043), being a case of clinically unsuccessful thrombolysis (HR, 7.72; 95% CI, 2.48-23.10; p = 0.0004), and the presence of diabetes mellitus (HR, 2.18; 95% CI, 1.01-4.71; p = 0.047) were independent predictors of a high MAE mortality rate at 12 months. For MALEs, statistically significant differences were detected with the variables history of Rutherford stage IIB (HR, 4.30; 95% CI, 1.99-9.31; p = 0.0002) and external iliac artery occlusion (HR, 31.27; 95% CI, 3.47-282.23; p = 0.0022). Conclusions: Based on the short-term results of CDT, acute limb ischaemia can be successfully, safely, and effectively treated with catheter-directed thrombolytic therapy with radial, brachial, or femoral access. However, radial access is associated with fewer access site complications. A history of Rutherford stage IIB, occlusion of external iliac artery, unsuccessful thrombolysis, and the presence of diabetes mellitus were independently associated with an increased risk of MAEs. A history of Rutherford stage IIB and external iliac artery occlusion are independent predictors of MALEs.
Collapse
Affiliation(s)
- Adam Csavajda
- Department of Invasive Cardiology, Bacs-Kiskun County Hospital, Teaching Hospital of the Albert Szent-Györgyi Medical School, University of Szeged, Nyiri Street 38, 6000 Kecskemet, Hungary; (K.T.); (N.K.); (S.R.); (Z.V.); (B.B.)
| | - Karoly Toth
- Department of Invasive Cardiology, Bacs-Kiskun County Hospital, Teaching Hospital of the Albert Szent-Györgyi Medical School, University of Szeged, Nyiri Street 38, 6000 Kecskemet, Hungary; (K.T.); (N.K.); (S.R.); (Z.V.); (B.B.)
| | - Nandor Kovacs
- Department of Invasive Cardiology, Bacs-Kiskun County Hospital, Teaching Hospital of the Albert Szent-Györgyi Medical School, University of Szeged, Nyiri Street 38, 6000 Kecskemet, Hungary; (K.T.); (N.K.); (S.R.); (Z.V.); (B.B.)
| | - Szilard Rona
- Department of Invasive Cardiology, Bacs-Kiskun County Hospital, Teaching Hospital of the Albert Szent-Györgyi Medical School, University of Szeged, Nyiri Street 38, 6000 Kecskemet, Hungary; (K.T.); (N.K.); (S.R.); (Z.V.); (B.B.)
| | - Zoltan Vamosi
- Department of Invasive Cardiology, Bacs-Kiskun County Hospital, Teaching Hospital of the Albert Szent-Györgyi Medical School, University of Szeged, Nyiri Street 38, 6000 Kecskemet, Hungary; (K.T.); (N.K.); (S.R.); (Z.V.); (B.B.)
| | - Balazs Berta
- Department of Invasive Cardiology, Bacs-Kiskun County Hospital, Teaching Hospital of the Albert Szent-Györgyi Medical School, University of Szeged, Nyiri Street 38, 6000 Kecskemet, Hungary; (K.T.); (N.K.); (S.R.); (Z.V.); (B.B.)
| | - Flora Zsofia Kulcsar
- Heart and Vascular Centre, Semmelweis University, Varosmajor Street 68, 1122 Budapest, Hungary; (F.Z.K.); (I.H.)
| | - Olivier F. Bertrand
- Quebec Heart-Lung Institute, Laval University, Quebec City, QC G1V 4G5, Canada;
| | - Istvan Hizoh
- Heart and Vascular Centre, Semmelweis University, Varosmajor Street 68, 1122 Budapest, Hungary; (F.Z.K.); (I.H.)
| | - Zoltan Ruzsa
- Department of Internal Medicine, Invasive Cardiology, Albert Szent-Györgyi Medical School, University of Szeged, Semmelweis Street 8, 6725 Szeged, Hungary;
| |
Collapse
|
3
|
Karonen E, Eek F, Butt T, Acosta S. Sex differences in outcomes after revascularization for acute lower limb ischemia: Propensity score adjusted analysis. World J Surg 2024; 48:746-755. [PMID: 38501573 DOI: 10.1002/wjs.12058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/13/2023] [Indexed: 03/20/2024]
Abstract
BACKGROUND Previous reports have suggested higher rates of mortality and amputation for female patients in acute lower limb ischemia (ALI). The aims of the present study were to investigate if there is a difference in mortality, amputation, and fasciotomy between the sexes. METHODS A retrospective cohort study of consecutive patients undergoing index revascularization for ALI between 2001 and 2018 was conducted. A propensity score was created through a logistic regression with female/male sex as an outcome. Cox regression analyses for 90-day and 1-year mortality, combining major amputation/mortality, and logistic regression for major bleeding and fasciotomy, were performed. All analyses were performed with and without adjusting for propensity score. RESULTS A total of 709 patients were included in the study of which 45.9% were women. Mean age was 72.1 years. Females were older and had higher rates of atrial fibrillation, embolic disease, and lower estimated glomerular filtration rate, while men more often had anemia and chronic peripheral arterial disease. Mortality at 1 year was 21.2% for women and 14.7% for men. The adjusted hazard ratio for 1-year mortality was 0.99 (95% CI 0.67-1.46). Fasciotomy was performed in 7.1% of female and 12.8% of male patients; the adjusted odds ratio was 0.52 (95% CI 0.29-0.91). CONCLUSION Sex was not found to be an independent risk factor for mortality or combined major amputation/mortality after revascularization for acute lower limb ischemia, whereas women had lower odds of undergoing fasciotomy. Whether women are underdiagnosed or do not develop acute compartment syndrome in the lower leg as often as men should be evaluated prospectively.
Collapse
Affiliation(s)
- Emil Karonen
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Frida Eek
- Department of Health Sciences, Lund University, Lund, Sweden
| | - Talha Butt
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden
- Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| |
Collapse
|
4
|
Gray BH, Wheibe E, Dicks AB, Low ML, Tingen JS. Pounce Thrombectomy System to Treat Acute and Chronic Peripheral Arterial Occlusions. Ann Vasc Surg 2023; 96:104-114. [PMID: 37244484 DOI: 10.1016/j.avsg.2023.05.019] [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: 03/23/2023] [Revised: 05/10/2023] [Accepted: 05/13/2023] [Indexed: 05/29/2023]
Abstract
Peripheral arterial occlusions are composed of variable amounts of thrombus. Endovascular techniques should initially address the variably aged thrombus prior to treating plaque (percutaneous transluminal angioplasty (PTA) ± stenting). This should ideally be accomplished in a single procedural session. Forty-four consecutive patients treated with the Pounce thrombectomy system (PTS) as captured in a retrospective database, who presented with acute (n = 18), subacute (n = 7), or chronic (n = 19) lower extremity ischemia, were treated and followed for a mean of 7 months. The peripheral occlusions were considered thrombus-dominant by the feel and ease of wire traversal. They were treated with PTS along with complimentary PTA/stenting when appropriate. The mean number of passes with PTS was 4.0 ± 2.7. Sixty-five percent (29/44) were successfully revascularized in a single setting with only 2 requiring concomitant thrombolysis for incomplete thrombus removal from the PTS target artery. An additional 15 patients (34%) had thrombolysis for tibial thrombus that was not attempted with PTS. PTA ± stenting after PTS occurred in 57% of limbs. Technical success was 83% and procedural success was 95%. Reintervention rate throughout follow-up was 22.7%. Major amputation occurred in 4.5%. Complications were limited to minor groin hematomas (n = 3). Outcomes were equally effective in patients with pre-existing stents or denovo arterial occlusions as evidenced with ankle brachial index improvement from 0.48 pre-to 0.93 postintervention and 0.95 at latest follow-up (P < 0.001). PTS coupled with PTA/stenting is expeditiously safe and effective in patients with thrombus-associated lower limb occlusion.
Collapse
Affiliation(s)
- Bruce H Gray
- Department of Surgery, Section of Vascular Surgery, University of South Carolina School of Medicine-Greenville, Greenville, SC.
| | - Elias Wheibe
- Department of Surgery, Section of Vascular Surgery, University of South Carolina School of Medicine-Greenville, Greenville, SC
| | - Andrew B Dicks
- Department of Surgery, Section of Vascular Surgery, University of South Carolina School of Medicine-Greenville, Greenville, SC
| | - Matthew L Low
- Department of Surgery, Section of Vascular Surgery, University of South Carolina School of Medicine-Greenville, Greenville, SC
| | - Joseph S Tingen
- Department of Surgery, Section of Vascular Surgery, University of South Carolina School of Medicine-Greenville, Greenville, SC
| |
Collapse
|
5
|
Stoklasa K, Sieber S, Naher S, Bohmann B, Kuehnl A, Stadlbauer T, Wendorff H, Biro G, Kallmayer MA, Knappich C, Busch A, Eckstein HH. Patients with Acute Limb Ischemia Might Benefit from Endovascular Therapy-A 17-Year Retrospective Single-Center Series of 985 Patients. J Clin Med 2023; 12:5462. [PMID: 37685530 PMCID: PMC10487798 DOI: 10.3390/jcm12175462] [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: 07/16/2023] [Revised: 08/11/2023] [Accepted: 08/18/2023] [Indexed: 09/10/2023] Open
Abstract
Acute lower limb ischemia (ALI) is a common vascular emergency, requiring urgent revascularization by open or endovascular means. The aim of this retrospective study was to evaluate patient demographics, treatment and periprocedural variables affecting the outcome in ALI patients in a consecutive cohort in a tertiary referral center. Primary outcome events (POE) were 30-day (safety) and 180-day (efficacy) combined mortality and major amputation rates, respectively. Secondary outcomes were perioperative medical and surgical leg-related complications and the 5-year combined mortality and major amputation rate. Statistical analysis used descriptive and uni- and multivariable Cox regression analysis. In 985 patients (71 ± 9 years, 56% men) from 2004 to 2020, the 30-day and 180-day combined mortality and major amputation rates were 15% and 27%. Upon multivariable analysis, older age (30 d: aHR 1.17; 180 d: 1.27) and advanced Rutherford ischemia stage significantly worsened the safety and efficacy POE (30 d: TASC IIa aHR 3.29, TASC IIb aHR 3.93, TASC III aHR 7.79; 180 d: TASC IIa aHR 1.97, TASC IIb aHR 2.43, TASC III aHR 4.2), while endovascular treatment was associated with significant improved POE after 30 days (aHR 0.35) and 180 days (aHR 0.39), respectively. Looking at five consecutive patient quintiles, a significant increase in endovascular procedures especially in the last quintile could be observed (17.5% to 39.5%, p < 0.001). Simultaneously, the re-occlusion rate as well as the number of patients with any previous revascularization increased. In conclusion, despite a slightly increasing early re-occlusion rate, endovascular treatment might, if possible, be favorable in ALI treatment.
Collapse
Affiliation(s)
- Kerstin Stoklasa
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
- Department of Vascular Surgery, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Sabine Sieber
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Shamsun Naher
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Bianca Bohmann
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Andreas Kuehnl
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Thomas Stadlbauer
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
- Department of Vascular Surgery, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Heiko Wendorff
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Gabor Biro
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Michael A. Kallmayer
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Christoph Knappich
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| | - Albert Busch
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
- Division of Vascular and Endovascular Surgery, Department of Visceral, Thoracic and Vascular Surgery, Medical Faculty Carl Gustav Carus and University Hospital, Technical University Dresden, 01307 Dresden, Germany
| | - Hans-Henning Eckstein
- Department for Vascular and Endovascular Surgery and Munich Aortic Center (MAC), University Hospital Rechts der Isar, Technical University Munich (TUM), Ismaninger Str. 22, 81675 Munich, Germany; (K.S.); (S.S.); (S.N.); (B.B.); (A.K.); (T.S.); (H.W.); (G.B.); (M.A.K.); (C.K.); (A.B.)
| |
Collapse
|
6
|
Doelare SAN, Koedam TWA, Ebben HP, Tournoij E, Hoksbergen AWJ, Yeung KK, Jongkind V. Catheter Directed Thrombolysis for Not Immediately Threatening Acute Limb Ischaemia: Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2023; 65:537-545. [PMID: 36608784 DOI: 10.1016/j.ejvs.2022.12.030] [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: 04/11/2022] [Revised: 11/29/2022] [Accepted: 12/23/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE This systematic review and meta-analysis reports the outcomes of catheter directed thrombolysis (CDT) in patients with not immediately threatening (Rutherford I) acute lower limb ischaemia (ALI). DATA SOURCES PubMed, Embase, and the Cochrane Library. REVIEW METHODS A systematic search of PubMed, Embase, and the Cochrane Library was performed to identify observational studies and trials published between 1990 and 2022 reporting on the results of CDT in patients with Rutherford I ALI. A meta-analysis was performed using a random effects model with 95% confidence intervals (CIs). The outcomes of interests were treatment duration, angiographic success, bleeding complications, amputation and mortality rates, primary and secondary patency, and functional outcome expressed as pain free walking distance. RESULTS Thirty-nine studies were included, comprising 1 861 patients who received CDT for not immediately threatening ALI. Funnel plots showed an indication of publication bias, and heterogeneity was substantial. Data from 5 to 13 studies were included in the meta-analysis. The pooled treatment duration was 2 days (95% CI 1 - 2), with an angiographic success rate of 80% (95% CI 73 - 86) and a 30 day freedom of amputation rate of 98% (95% CI 92 - 100). The major bleeding rate was 5% (95% CI 2 - 14), with a 30 day mortality rate of 3% (95% CI 1 - 5). The amputation free survival rate was 71% (95% CI 62 - 80) at the one year and 63% (95% CI 51 - 73) at the three year follow up. Long term patency rates were retrieved from four studies: 48% at one year (95% CI 27 - 70). No data could be retrieved on patient walking distance. CONCLUSION Although CDT in the treatment of not immediately threatening ALI showed high angiographic success, the long term outcomes were relatively poor, with low patency and a substantial risk of major amputation. Further research is required to interpret the outcome of CDT in the context of potential confounders such as age and comorbidities.
Collapse
Affiliation(s)
- Sabrina A N Doelare
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Vrije Universiteit Amsterdam, Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands.
| | - Thomas W A Koedam
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Surgery, Dijklander Hospital, Hoorn, the Netherlands
| | - Harm P Ebben
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Vrije Universiteit Amsterdam, Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Erik Tournoij
- Department of Surgery, Dijklander Hospital, Hoorn, the Netherlands
| | - Arjan W J Hoksbergen
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Kak K Yeung
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Vrije Universiteit Amsterdam, Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
| | - Vincent Jongkind
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Surgery, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Vrije Universiteit Amsterdam, Department of Physiology, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands; Department of Surgery, Dijklander Hospital, Hoorn, the Netherlands
| |
Collapse
|
7
|
Patel HP, Decter D, Thakkar S, Anantha-Narayanan M, Kumar A, Sheth AR, Zahid S, Patel BA, Patel T, Devani H, Shah V, Doshi PM, Patel S, Shariff M, Adalja D, Vallabhajosyula S, Doshi R. Impact of Chronic Kidney Disease on In-Hospital Outcomes of Hospitalizations With Acute Limb Ischemia Undergoing Endovascular Therapy. J Endovasc Ther 2022:15266028221134887. [PMID: 36401519 DOI: 10.1177/15266028221134887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE Studies on outcomes related to endovascular treatment (EVT) in advanced stages of chronic kidney disease (CKD) and end-stage renal disease (ESRD) among hospitalizations with acute limb ischemia (ALI) are limited. METHODS The Nationwide Inpatient Sample was quarried from October 2015 to December 2017 to identify the hospitalizations with ALI and undergoing EVT. The study population was subdivided into 3 groups based on their CKD stages: group 1 (No CKD, stage I, stage II), group 2 (CKD stage III, stage IV), and group 3 (CKD stage V and ESRD). The primary outcome was all-cause in-hospital mortality. RESULTS A total of 51 995 hospitalizations with ALI undergoing EVT were identified. The in-hospital mortality was significantly higher in group 2 (OR = 1.17; 95% CI 1.04 - 1.32, p=0.009) and group 3 (OR = 3.18; 95% CI 2.74-3.69, p<0.0001) compared with group 1. Odds of minor amputation, vascular complication, atherectomy, and blood transfusion were higher among groups 2 and 3 compared with group 1. Group 2 had higher odds of access site hemorrhage compared with groups 1 and 3, whereas group 3 had higher odds of major amputation, postprocedural infection, and postoperative hemorrhage compared with groups 1 and 2. Besides, groups 2 and 3 had lower odds of discharge to home compared with group 1. Finally, the length of hospital stay and cost of care was significantly higher with the advancing CKD stages. CONCLUSION Advanced CKD stages and ESRD are associated with higher mortality, worse in-hospital outcomes and higher resource utilization among ALI hospitalizations undergoing EVT. CLINICAL IMPACT Current guidelines are not clear for the optimum first line treatment of acute limb ischemia, especially in patients with advanced kidney disease as compared to normal/mild kidney disease patients. We found that advanced kidney disease is a significant risk factor for worse in-hospital morbidity and mortality. Furthermore, patients with acute limb ischemia and advanced kidney disease is associated with significantly higher resource utilization as compared to patients with normal/mild kidney disease. This study suggests shared decision making between treating physician and patients when considering endovascular therapy for the treatment of acute limb ischemia in patients with advanced kidney disease.
Collapse
Affiliation(s)
- Harsh P Patel
- Department of Internal Medicine, Louis A. Weiss Memorial Hospital, Chicago, IL, USA
| | - Dean Decter
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Mahesh Anantha-Narayanan
- Department of Interventional Cardiology, The University of Arizona and Banner University Medical Center, Phoenix, AZ, USA
| | - Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH, USA
| | - Aakash R Sheth
- Department of Internal Medicine, Louisiana State University, Shreveport, LA, USA
| | - Salman Zahid
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Bhavin A Patel
- Department of Cardiology, Apex Heart Institute, Ahmedabad, India
| | - Toralben Patel
- Department of Cardiovascular Diseases, AdventHealth Medical Group, Orlando, FL, USA
| | - Hiteshkumar Devani
- Department of Dental Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Vrushali Shah
- Department of Endocrinology, University of Massachusetts, Worcester, MA, USA
| | | | - Smit Patel
- Department of Internal Medicine, Vassar Brothers Medical Center, Poughkeepsie, NY, USA
| | | | - Devina Adalja
- Department of Medicine, Gujarat Medical Education & Research Society Gotri Medical College, Vadodara, India
| | | | - Rajkumar Doshi
- Department of Internal Medicine, University of Nevada Reno School of Medicine, NV, USA
| |
Collapse
|
8
|
Kulezic A, Acosta S. Epidemiology and Prognostic Factors in Acute Lower Limb Ischaemia: A Population Based Study. Eur J Vasc Endovasc Surg 2022; 63:296-303. [PMID: 35027271 DOI: 10.1016/j.ejvs.2021.10.044] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 09/28/2021] [Accepted: 10/15/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the contemporary population based incidence of acute lower limb ischaemia (ALI) and factors associated with major amputation/death at one year. METHODS In this retrospective observational study, in hospital, operation, radiological, and autopsy registries were scrutinised to capture 161 citizens of Malmö, Sweden, with ALI between 2015 and 2018. Age and sex specific incidence rates were calculated in the population of Malmö between 2015 and 2018, expressed as number of patients per 100 000 person years (PY). Independent risk factors for major amputation/death at one year were identified by multivariable logistic regression analysis and expressed as odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS One hundred and sixty-one patients with ALI gave an overall incidence of 12.2/100 000 PY (95% CI 10.3 - 14.1), with no sex related differences. Embolism (42.2%) was the most common cause of ALI. Among 52 patients with atrial fibrillation, 38.5% were on anticoagulant medication. Endovascular or open vascular revascularisation was performed in 54.7% of patients. The total cause specific mortality ratio was 2.63 (95% CI 1.66 - 3.61)/1 000 deaths, without no sex related differences. The combined major amputation/mortality rate at one year for the whole cohort was 46.6%. Rutherford ≥ IIb ALI (OR 4.19, 95% CI 1.94 - 9.02; p < .001), age (OR 1.03/year, 95% CI 1.00 - 1.06; p = .036), female sex (OR 2.37, 95% 1.07 - 5.26; p = .034), and anaemia (OR 2.46, 95% CI 1.08 - 5.62; p = .033) were associated with an increased risk of major amputation/death at one year. The major amputation/mortality rate at one year was 100% (n = 14/14) for patients living in a nursing home on admission. CONCLUSION The incidence of ALI appears to be unchanged, and major amputation and mortality at one year remain high. It is necessary to include the substantial proportion of patients with ALI that do not undergo revascularisation in epidemiological studies. There is room for improvement in anticoagulation therapy in patients with atrial fibrillation to prevent ALI due to embolism. Research on gender inequalities in patients with ALI is warranted.
Collapse
Affiliation(s)
- Andrea Kulezic
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden; Vascular Centre, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden.
| |
Collapse
|
9
|
Gong M, Zhou Y, He X, Chen L, Zhao B, Kong J, Su H, Gu J. Mechanical revascularization using Solitaire AB device for acute limb ischemia secondary to popliteal and infrapopliteal embolic occlusion. Digit Health 2022; 8:20552076221084467. [PMID: 35340902 PMCID: PMC8943301 DOI: 10.1177/20552076221084467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/14/2022] [Indexed: 11/28/2022] Open
Abstract
Objective Acute limb ischemia is one of the most common arterial emergencies. The data of mechanical revascularization using Solitaire AB device coupled with thromboaspiration for the treatment of popliteal and infrapopliteal acute limb ischemia are limited. The aim of this study was to review the preliminary safety and effectiveness. Methods We performed a single-center retrospective review of patients with popliteal and infrapopliteal acute limb ischemia treated with Solitaire AB device coupled with thromboaspiration from February 2019 to May 2020. Adjunctive balloon angioplasty was performed to correct coexisting atherosclerotic stenosis. Technical success was defined as successful deployment of the Solitaire AB device across the occlusive segment and successful retrieval without the use of adjunctive catheter-directed thrombolysis or balloon angioplasty. Clinical success was defined as the relief of symptoms related to acute limb ischemia. Follow-up outcomes were also reviewed. Results There were 15 consecutive patients who underwent 16 Solitaire AB devices. Technical success was achieved in 11 (73.3%) patients. Of the unsuccessful patients, double-stent retrievers were employed in 1 (6.7%) patient. Two patients who encountered residual clots in distal small arteries underwent adjunctive catheter-directed thrombolysis. An adjunctive balloon angioplasty was required in 1 (6.7%) patient. All patients had notable acute limb ischemia symptom relief after the procedures. Clinical success was achieved in 14 (93.3%) patients. Besides one patient encountered minor amputation, the major amputation was prevented in all patients. No device-related complications or distal embolization events were recorded during the procedures. At the follow-up of 12 months, all surviving patients remained symptom-free, the patency was achieved in 12 (80%) patients and the limb salvage was 100%. Conclusions Preliminary outcomes suggest that mechanical revascularization using Solitaire AB device coupled with manual thromboaspiration appears to be a rapid, safe, and effective modality that appears to reduce the requirement for catheter-directed thrombolysis. Advances in knowledge These findings may add a promising recanalization therapy for acute embolic occlusion of the acute limb ischemia secondary to popliteal and infrapopliteal arteries.
Collapse
Affiliation(s)
- Maofeng Gong
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Yangyi Zhou
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Xu He
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Liang Chen
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Boxiang Zhao
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Jie Kong
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Haobo Su
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| | - Jianping Gu
- Department of Vascular and Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu PR China
| |
Collapse
|
10
|
[Application of Rotarex mechanical thrombectomy system in acute lower limb ischemia]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021. [PMID: 34916698 PMCID: PMC8695157 DOI: 10.19723/j.issn.1671-167x.2021.06.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the effectiveness and safety of Rotarex mechanical thrombectomy system in treating acute lower limb ischemia. METHODS From December 2017 to December 2019, the clinical data of 23 acute lower limb ischemia cases treated with Rotarex mechanical thrombectomy system were retrospectively analyzed. There were 14 males and 9 females from 53- to 84-year-old patients and the mean age was (69.1±9.1) years. Duration of symptoms was 6 hours to 14 days (median time 7 days). In the study, 8 acute thromboembolism cases and 15 acute thrombosis cases were included (In which, there was one thromboangiitis obliterans case and two in-stent restenosis cases). In 5 cases, the lesions were located above the groin; in 16 cases, the lesions were located below the groin, and in the other 2 cases, the lesions were located both above and below the groin. All the cases were treated with Rotarex mechanical thrombectomy system. When residual stenosis was greater than 50%, percutaneous transluminal angioplasty (PTA) was used, and stent was used only when it was necessary. Heparin was used 24 h after the procedure, and after that, antiplatelet agents were used in acute thrombosis cases, and oral anti-coagulants were used in acute thromboembolism cases. Doppler ultrasonography was taken during the follow-up. RESULTS In all the 23 cases, there were 22 successful cases and 1 unsuccessful case, the mean procedure time was (68.2±15.6) min. Percutaneous transluminal angioplasty was used in 18 cases, 7 of which were implanted stents (3 stents were implanted in iliac artery and 4 in superficial femoral artery). There were 3 procedure related complications. The first one was arterial wall injury which resulted in contrast medium extravazation, and in this case, we solved it with prolonged balloon inflation. The second one was distal embolism. We took out the thrombus with guiding catheter. The last one was acute occlusion in a stent, and thrombectomy was applied urgently, and the result was good. Mean hospital stay were (3.6±1.7) days. The ankle brachial index (ABI) increased from 0.25±0.10 to 0.85±0.16 after treatment (t=12.901, P < 0.001). All the patients were followed up for 4.0-28.0 months, and the median time was 12.0 months. One patient stopped antiplatelet agents, which resulted in acute thrombosis 2 months later. Another percutaneous mechanical thrombectomy and PTA were taken. In the failed case, the patient suffered amputation above the knee 3 months later and in another case, the patient died of heart failure 8 months after the procedure. Two target lesion restenosis occurred during the follow-up. Because the patients' symptom was not sever, no procedure was taken. CONCLUSION Percutaneous mechanical thrombectomy using Rotarex catheter is safe and effective in treating acute lower limb ischemia. For one side, it can restore blood flow to the affected limbs quickly, and for the other, it has the characteristics of minimally invasive and good repeatability. So it should be considered that this me-thod can be widely used for acute lower limb ischemia.
Collapse
|
11
|
Tsujimura T, Takahara M, Iida O, Kohsaka S, Soga Y, Fujihara M, Mano T, Ohya M, Shinke T, Amano T, Ikari Y. In-Hospital Outcomes after Endovascular Therapy for Acute Limb Ischemia: A Report from a Japanese Nationwide Registry [J-EVT Registry]. J Atheroscler Thromb 2021; 28:1145-1152. [PMID: 33229856 PMCID: PMC8592702 DOI: 10.5551/jat.60053] [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] [Indexed: 01/12/2023] Open
Abstract
Aim:
The aim of the current study was to describe the clinical profile, frequency of in-hospital complications, and predictors of adverse events in patients undergoing endovascular therapy (EVT) for acute limb ischemia (ALI), and to compare them with those of patients undergoing EVT for chronic symptomatic peripheral artery disease (PAD).
Methods:
The current study compared 2,398 cases of EVT for ALI with 74,171 cases of EVT for chronic symptomatic PAD performed between January 2015 and December 2018 in Japan. We first compared the clinical profiles of ALI patients with those of PAD patients. We then evaluated the proportion of in-hospital complications and investigated their risk factors in the ALI patients. The association of clinical characteristics with the risk of in-hospital complications was analyzed via logistic regression modeling.
Results:
Patients with ALI were older and had a higher prevalence of female sex, impaired mobility, and history of cerebrovascular disease, but a lower prevalence of cardiovascular risk factors and history of coronary artery disease. The proportion of in-hospital EVT-related complications in ALI was 6.1% and was significantly higher compared with those in chronic symptomatic PAD patients (2.0%,
P
<0.001). Bedridden status (adjusted odds ratio [aOR], 1.74 [1.14 to 2.66];
P
=0.010), history of coronary artery disease (aOR, 1.80 [1.21 to 2.68];
P
=0.004), and a suprapopliteal lesion (aOR, 1.70 [1.05 to 2.74];
P
=0.030) were identified as independent risk factors for in-hospital complications.
Conclusion:
The current study demonstrated that ALI patients with significant comorbidities show a higher proportion of in-hospital complications after EVT.
Collapse
Affiliation(s)
| | - Mitsuyoshi Takahara
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine.,Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
| | | | | | | | - Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital
| | - Toshiro Shinke
- Department of Cardiology, Showa University School of Medicine
| | | | - Yuji Ikari
- Division of Cardiovascular Medicine, Tokai University Hospital
| |
Collapse
|
12
|
Butt T, Lehti L, Apelqvist J, Gottsäter A, Acosta S. Contrast-Associated Acute Kidney Injury in Patients with and without Diabetes Mellitus Undergoing Computed Tomography Angiography and Local Thrombolysis for Acute Lower Limb Ischemia. Vasc Endovascular Surg 2021; 56:151-157. [PMID: 34670450 PMCID: PMC8796150 DOI: 10.1177/15385744211051503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PurposeRepetitive iodinated contrast media exposure may be harmful for the kidneys. The aim of the present study was to evaluate if patients with diabetes mellitus (DM) undergoing CT angiography (CTA) and local continuous thrombolysis for acute lower limb ischemia (ALI) had an increased risk of developing contrast-associated acute kidney injury (CA-AKI) compared to patients without DM. Methods: This is a retrospective study of patients undergoing CTA and local continuous thrombolysis due to ALI between 2001 and 2018. CA-AKI was defined as a 25% increase in serum creatinine within 72 hours after latest contrast administration. Results: There was no difference (P = .30) in the frequency of CA-AKI between patients with (27.9%; n = 43) and without DM (20.6%; n = 170). Among patients with CA-AKI, patients with DM had a lower (P < .001) estimated glomerular filtration rate (eGFR) at discharge (55 ml/min/1.73 m2) than at admission (70 ml/min/1.73 m2), while no such difference was found in the group without DM (P = .20). The gram-iodine dose/eGFR ratio was higher (P < .001) in patients with CA-AKI (median 1.49, [IQR 1.34-1.81]) than in those who did not develop CA-AKI (median 1.05 [IQR 1.00-1.13]). There was a trend that gram-iodine dose/eGFR ratio (OR 1.42/standard deviation increment, 95% CI 1.00-2.02; P = .050) was associated with an increased risk of CA-AKI, after adjusting for DM, age, and gender. Conclusions: The frequency of CA-AKI was high after CTA and local continuous thrombolysis for ALI without shown increased frequency for the DM group. Among patients with CA-AKI, however, patients with DM had worse renal function at discharge than those without DM. The gram-iodine dose/eGFR ratio in these patients needs to be lower to improve renal outcomes, particularly in patients with DM.
Collapse
Affiliation(s)
- Talha Butt
- Department of Clinical Sciences, 174435Lund University, Malmo, Sweden.,Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Malmo, Sweden
| | - Leena Lehti
- Department of Clinical Sciences, 174435Lund University, Malmo, Sweden.,Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Malmo, Sweden
| | - Jan Apelqvist
- Department of Clinical Sciences, 174435Lund University, Malmo, Sweden.,Department of Endocrinology, Skåne University Hospital, Malmo, Sweden
| | - Anders Gottsäter
- Department of Clinical Sciences, 174435Lund University, Malmo, Sweden.,Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Malmo, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, 174435Lund University, Malmo, Sweden.,Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Malmo, Sweden
| |
Collapse
|
13
|
Khuda Bakhsh Z, Khan R, Al-Khafaji F, Achyuth Suresh V, Bashir K. Thrombosis of Bilateral Profunda Femoris, Anterior Tibial, and Tibioperoneal Arteries in a Patient With COVID-19 Infection. Cureus 2021; 13:e17623. [PMID: 34646673 PMCID: PMC8486359 DOI: 10.7759/cureus.17623] [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] [Accepted: 08/31/2021] [Indexed: 12/02/2022] Open
Abstract
COVID-19, also known as severe acute respiratory distress syndrome coronavirus 2, mostly affects the respiratory system causing acute respiratory syndrome. It not only targets lungs but also causes vascular endothelial disruption, which can lead to arterial or venous thrombosis causing ischemia, which increases the morbidity and mortality in some patients, if not recognized and treated in a timely manner. We present an interesting case of a patient recovering from COVID-19 pneumonia , who developed bilateral foot ischemia due to thrombosis of bilateral profunda femoris, bilateral anterior tibial, and tibioperoneal arteries. A 44-year-old gentleman presented to the emergency department complaining of severe bilateral foot pain, which progressively got worse. Upon examination he had blue toes bilaterally with absent dorsalis pedis and posterior tibial pulse. CT angiogram was performed, which showed severe multilevel lower limb arterial occlusions involving bilateral profunda femoris, bilateral anterior tibial, and tibioperoneal arteries. The patient was initially thrombolyzed and later underwent thrombectomy with the assistance of interventional radiologist. Hospital course was uneventful, and the patient was discharged on warfarin following complete resolution of symptoms.
Collapse
Affiliation(s)
| | - Raheel Khan
- Emergency Medicine, Hamad Medical Corporation, Doha, QAT.,Emergency Medicine, Hamad General Hospital, Doha, QAT
| | | | | | - Khalid Bashir
- Medicine, Qatar University, Doha, QAT.,Emergency Medicine, Hamad Medical Corporation, Doha, QAT
| |
Collapse
|
14
|
Ruiz-Carmona C, Clara A, Casajuana E, Marcos L, Romero L, Velescu A. Clinical Clues for the Current Diagnosis of Acute Lower Limb Ischemia: A Contemporary Case Series. Ann Vasc Surg 2021; 79:174-181. [PMID: 34656718 DOI: 10.1016/j.avsg.2021.07.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Acute lower limb ischemia (ALI) is a limb and life-threatening condition whose treatment largely depends on the underlying cause. The clinical distinction between the main causes may have changed over the years because of changes in the epidemiology of this syndrome. The objective of this study was to determine the clinical pattern associated with the main causes of ALI in a contemporary series of cases. METHODS We retrospectively reviewed all consecutive ALI cases admitted to a tertiary hospital between 2007 and 2019. ALI secondary to other conditions than embolism or NAT were excluded. The association between clinical variables and the ALI cause was assessed with multiple logistic regressions and the discriminative power of the resulting clinical predictive scores with the area under the ROC curve. RESULTS The study group included 243 patients (mean age 77.2 years; 52.7% male), of which 140 (57.6%) were caused by an arterial embolism and 103 (42.4%) by a NAT. Among these latter, 78 (75.7%) were related to an atherosclerotic NAT and 25 (24.3%) to a complicated popliteal aneurysm. Independent risk factors associated with embolism included atrial fibrillation (OR 10.26, 95% CI 5.1 - 20.67) or female gender (OR 5.44, 95% CI 2.76 - 10.71), but not the severity of the episode or the presence of contralateral pulses. Those related to a NAT included a previous symptomatic peripheral arterial disease (OR 2.68, 95% CI 1.35 - 5.35) and seeking consultation more than 24 hours after the beginning of symptoms (OR 2.57, 95% CI 1.32 - 5), but not a higher rate of other vascular risk factors. Among patients with NAT, previous intermittent claudication (OR 8.34, 95% CI 2.42 - 28.72) and >24 hs delay of arrival of the patient (OR 4.78, 95% CI 1.48 - 15.43) were more frequent among those related to an atherosclerotic NAT, whereas higher hemoglobin levels (OR 1.60, 95% CI 1.21 - 2.11) and non-significantly the history of tobacco smoking (OR 2.95, 95% CI 0.84 - 10.36) among those with a popliteal aneurysm-related NAT. The discriminative power of the two clinical models resulting from these predictive variables for differentiating embolism from NAT and atherosclerosis-related NAT from popliteal aneurysm-related NAT was excellent (0.86 and 0.85, respectively). CONCLUSION Certain clinical features appear to be no longer useful in the distinction between embolism and NAT, while others may help in the differential diagnosis between atherosclerotic and popliteal aneurysm-related NAT. Surgeons must be aware of possible changes in the presentation of ALI because time constraints are frequent and clinical data remain essential.
Collapse
Affiliation(s)
- Carlos Ruiz-Carmona
- Vascular Surgery Department, Hospital del Mar, Barcelona, Spain; Departament de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Albert Clara
- Vascular Surgery Department, Hospital del Mar, Barcelona, Spain; Departament de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain; CIBER Cardiovascular, Barcelona, Spain.
| | - Eduard Casajuana
- Vascular Surgery Department, Hospital del Mar, Barcelona, Spain; Departament de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lidia Marcos
- Vascular Surgery Department, Hospital del Mar, Barcelona, Spain; Departament de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lorena Romero
- Vascular Surgery Department, Hospital del Mar, Barcelona, Spain; Departament de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alina Velescu
- Vascular Surgery Department, Hospital del Mar, Barcelona, Spain; Departament de Cirurgia, Universitat Autònoma de Barcelona, Barcelona, Spain; CIBER Cardiovascular, Barcelona, Spain
| |
Collapse
|
15
|
Karonen E, Wrede A, Acosta S. Risk Factors for Fasciotomy After Revascularization for Acute Lower Limb Ischaemia. Front Surg 2021; 8:662744. [PMID: 33855045 PMCID: PMC8039517 DOI: 10.3389/fsurg.2021.662744] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/08/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Acute lower limb ischaemia (ALI) is a life and limb threatening vascular emergency. Acute compartment syndrome (ACS) may develop upon revascularization. The risk of fasciotomy was hypothesized to be decreased in women due to their lower calf muscle mass. The main aim was to evaluate risk factors for fasciotomy after revascularization for ALI. Methods: This is a retrospective observational study of patients undergoing revascularization for ALI between 2001 and 2018. Factors associated with outcome at 1 year in univariable analysis (p < 0.1) were chosen for multi-variable analysis and expressed in Odds Ratios (OR) with 95% confidence intervals (CI). Results: The median age for women (n = 394) was 75 years and men (n = 449) was 70 years (p < 0.001). The frequency of fasciotomy was 10.0% (84/843). The median in-hospital stay was 28 vs. 6 days for patients undergoing fasciotomy and not, respectively (p < 0.001). In adjusted analysis, renal insufficiency (OR 1.77, 95% CI 1.04–3.01), motor deficit (OR 4.40, 95% CI 2.45–7.92), popliteal artery aneurysm thromboembolism (OR 2.26, 95% CI 1.06–4.80), and open vascular surgery (OR 3.43, 95% CI 1.97–5.98) were associated with an increased risk of fasciotomy. Female patients (OR 0.49, 95% CI 0.28–0.84) and anemia (OR 0.52, 95% CI 0.28–0.84) had a lower risk. The major amputation/mortality rate at 1-year was 27.7%; fasciotomy (OR 1.94, 95% CI 1.11–3.40), anemia (OR 1.84, 95% CI 1.24–2.73) and female gender (OR 1.44, 95% CI 1.00–2.08) were independently associated with an increased risk. Conclusions: Female patients had lower rates of fasciotomies, but subsequent higher risk of major amputation/mortality, which may be attributed to inferior results of revascularization. Lower muscle mass and underdiagnosis of ACS could also explain the lower frequency of fasciotomy for female patients. Further studies are needed to better understand gender differences in presentation of ALI, revascularization results and diagnosis of ACS.
Collapse
Affiliation(s)
- Emil Karonen
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Vascular Center, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Axel Wrede
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Vascular Center, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Lund University, Malmö, Sweden.,Vascular Center, Department of Cardiothoracic and Vascular Surgery, Skåne University Hospital, Malmö, Sweden
| |
Collapse
|
16
|
Skripochnik E, Bannazadeh M, Jasinski P, Loh SA. Mid-Term Outcomes of Thrombolysis for Acute Lower Extremity Ischemia at a Tertiary Care Center. Ann Vasc Surg 2020; 69:317-323. [PMID: 32502677 DOI: 10.1016/j.avsg.2020.05.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/13/2020] [Accepted: 05/19/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Acute limb ischemia (ALI) is challenging to treat because of high morbidity and mortality. Endovascular-first options beginning with thrombolysis are technically feasible with similar results to open surgery. We examined our experience with thrombolysis to identify patients and target conduits that are predictive of improved outcomes. METHODS We performed a retrospective review of our institutional database of thrombolysis cases for arterial lower extremity disease. Thrombolysis was the index procedure, and any subsequent treatment was a reintervention. Conversion to open surgery perioperatively such as thromboembolectomy or bypass was considered a technical failure. Primary outcomes included primary patency, secondary patency, amputation-free survival (AFS), and survival. Secondary outcomes included conversion to open, reintervention <30 days, and amputation <30 days. Descriptive statistics and analysis of variance were performed for preoperative and intraoperative risk factors. Kaplan-Meier estimation and Cox proportional hazard models were used for primary and secondary outcomes. RESULTS Ninety-nine patients with ALI were treated with thrombolysis from 2007 to 2017. Thrombolysis was attempted on native artery (40%), vein bypass (7%), prosthetic bypass (33%), and stent (19%). Rutherford class distribution was 50% class 1, 41% class 2a, 5% class 2b, and 3% class 3. Technical success was 70%, characterized by an all-endovascular approach, patency at 30 days, and AFS for 30 days. Primary patency at 1- and 2-years was 31% and 22%, respectively. Secondary patency at 1- and 2-years was 39% and 27%, respectively. Overall, 30% required conversion to open surgery at the time of the index procedure, 7% reintervention <30 days, 5% mortality <30 days, and 5% major amputation <30 days. Prosthetic grafts and vein bypasses had the worst primary and secondary patency (P < 0.05). Five out of 7 vein bypasses required open conversion. Thrombolysis of native arteries was most successful maintaining primary patency (P < 0.05), secondary patency (P < 0.05), and AFS (P < 0.05). Patients who had adjunctive procedures at the time of thrombolysis had a significantly greater primary patency (P < 0.05) and secondary patency (P < 0.05) but not greater AFS. CONCLUSION Outcomes in thrombolysis for ALI have not significantly improved 20 years after the STILE trial. Technical success and mid-term patency rates are modest at best. Thrombolysis of vein bypasses and prosthetic grafts have poor technical success and primary patency compared with native arteries. However, aggressive adjunctive interventions during thrombolysis appear to improve primary and secondary patency.
Collapse
Affiliation(s)
- Edvard Skripochnik
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Medical Center, Health Sciences Center T19-090, Stony Brook Medicine, Stony Brook, NY
| | - Mohsen Bannazadeh
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Medical Center, Health Sciences Center T19-090, Stony Brook Medicine, Stony Brook, NY
| | - Patrick Jasinski
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Medical Center, Health Sciences Center T19-090, Stony Brook Medicine, Stony Brook, NY
| | - Shang A Loh
- Division of Vascular and Endovascular Surgery, Department of Surgery, Stony Brook University Medical Center, Health Sciences Center T19-090, Stony Brook Medicine, Stony Brook, NY.
| |
Collapse
|
17
|
Abstract
Background: Endovascular therapy for acute lower limb ischemia (ALLI) has developed and
demonstrated safety and efficacy. The purpose of this study was to assess
clinical outcomes in patients treated for ALLI with conventional
endovascular or surgical revascularization. Method: This study was a retrospective single-center review. Consecutive patients
with ALLI treated with conventional endovascular revascularization (ER)
without thrombolytic agent or surgical revascularization (SR) between 2008
and 2014 were investigated. The 1 year and 3 year amputation rate and
mortality rate were assessed by time-to-event methods, including
Kaplan–Meier estimation. Result: A total of 64 limbs in 62 patients with ALLI due to thromboembolism or
thrombosis of a native artery, bypass graft, or previous stented vessel were
included. The majority of limbs (90.9%) presented with Rutherford clinical
categories 1 to 2 ischemia. Technical success rate was 95.5% in ER and 92.9%
in SR group (p = 0.547). Overall amputation rates were 9.1%
in ER versus 9.5% in SR after 1 year
(p = 0.971) and 9.1% in ER versus 11.9% in
SR after 3 year (p = 0.742). Overall mortality rates were
15% in ER versus 7.1% in SR after 1 year
(p = 0.491) and 15% in ER versus 11.2%
in SR after 3 year (p = 0.878). Conclusion: Endovascular or surgical revascularization of ALLI resulted in comparable
outcomes in limb salvage and mortality rate at 1 year and 3 year.
Conventional endovascular therapy without thrombolytic agent such as
stenting, balloon angioplasty, or catheter-directed thrombosuction may be
considered as a treatment option for ALLI.
Collapse
Affiliation(s)
- Keisuke Fukuda
- Department of Cardiology, Kishiwada Tokushukai Hospital, 4-27-1 Kamori-cho, Kishiwada City, Osaka, Japan 596-8522
| | - Yoshiaki Yokoi
- Department of Cardiology, Kishiwada Tokushukai Hospital, Kishiwada City, Osaka, Japan
| |
Collapse
|
18
|
Núñez-Rojas G, Lozada-Martinez ID, Bolaño-Romero MP, Ramírez-Barakat E. Isquemia arterial aguda de las extremidades: ¿cómo abordarla? REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
La isquemia arterial aguda de las extremidades se define como la interrupción abrupta del flujo sanguíneo a determinado tejido, lo cual afecta la integridad, la viabilidad de la extremidad, o ambas. Las causas son múltiples y pueden resumirse en dos procesos fisiopatológicos, trombóticos o embólicos, con lo que se puede establecer el pronóstico y el tratamiento según su causa.
El cuadro sindrómico es variable, y típicamente, se identifica con las cinco “P” de Pratt (pain, pallor, pulselessness, paralysis and paresthesia); se cuenta con múltiples ayudas diagnósticas, pero la arteriografía sigue siendo el método estándar para el diagnóstico.
Con el advenimiento de los avances tecnológicos y los procedimientos vasculares, el salvamento de las extremidades ha venido en aumento y ha disminuido la extensión de las amputaciones, lo cual conlleva una mayor tasa de rehabilitación y de reincorporación a la vida social.
Collapse
|
19
|
Björck M, Earnshaw JJ, Acosta S, Bastos Gonçalves F, Cochennec F, Debus ES, Hinchliffe R, Jongkind V, Koelemay MJW, Menyhei G, Svetlikov AV, Tshomba Y, Van Den Berg JC, Esvs Guidelines Committee, de Borst GJ, Chakfé N, Kakkos SK, Koncar I, Lindholt JS, Tulamo R, Vega de Ceniga M, Vermassen F, Document Reviewers, Boyle JR, Mani K, Azuma N, Choke ETC, Cohnert TU, Fitridge RA, Forbes TL, Hamady MS, Munoz A, Müller-Hülsbeck S, Rai K. Editor's Choice - European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg 2019; 59:173-218. [PMID: 31899099 DOI: 10.1016/j.ejvs.2019.09.006] [Citation(s) in RCA: 223] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
20
|
Combined treatment (image-guided thrombectomy and endovascular therapy with open femoral access) for acute lower limb ischemia: Clinical efficacy and outcomes. PLoS One 2019; 14:e0225136. [PMID: 31730625 PMCID: PMC6857913 DOI: 10.1371/journal.pone.0225136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/29/2019] [Indexed: 11/19/2022] Open
Abstract
Objectives To evaluate the effectiveness and safety of combined treatment (image guided thrombectomy and endovascular therapy with open femoral access) for acute lower limb ischemia. Methods From 2009 to 2017, 52 patients (44 men, eight women, mean 67.2 years) underwent combined treatment for acute thrombotic occlusion of lower extremity arteries. The patients presented with acute limb ischemia and we selectively perform combined treatment in the cases with challenging clinical considerations (e.g. various spectrum of thrombus, underlying atherosclerotic lesions). Combined treatment included cutdown of common femoral artery, thrombectomy using a Fogarty balloon catheter, balloon angioplasty, stenting, and catheter-introduced thrombus fragmentation and aspiration. Patients’ medical records were retrospectively reviewed and follow-up data were collected. The technical and clinical success rates and limb salvage were assessed. The Kaplan-Meier method was used to analyze primary patency rates and overall survival rates. Univariate analyses were performed to determine the factors related to clinical outcomes. Results Technical and clinical success rate was 90.4% and 80.8%, respectively. The mean follow-up duration was 26.5 ± 25.8 months. Primary patency was 91.4%, 86.1%, and 74.6% at six months, 1-, and 2-year, respectively. Limb salvage without amputation was 88.5% (46/52). The overall survival rates at six months, 1-, and 3-year were 82.6%, 80.2, and 56.9%, respectively. The 30-day mortality was 5.8% (3/52). Univariate analysis showed that percutaneous transluminal angioplasty (PTA) type (balloon versus stent) was related to clinical failure. Conclusions Combined treatment can be effective and safe for ALI patients even under challenging clinical conditions.
Collapse
|
21
|
Umetsu M, Akamatsu D, Goto H, Ohara M, Hashimoto M, Shimizu T, Sugawara H, Tsuchida K, Yoshida Y, Tajima Y, Suzuki S, Horii S, Watanabe T, Miyagi S, Unno M, Kamei T. Long-Term Outcomes of Acute Limb Ischemia: A Retrospective Analysis of 93 Consecutive Limbs. Ann Vasc Dis 2019; 12:347-353. [PMID: 31636745 PMCID: PMC6766766 DOI: 10.3400/avd.oa.19-00018] [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] [Indexed: 11/26/2022] Open
Abstract
Objective: To examine the medium- to long-term outcomes of acute limb ischemia (ALI), which are unclear at present. Methods: We analyzed 93 consecutive limbs in 77 patients with ALI between January 2005 and December 2015 treated at our vascular center. We categorized the cases into four groups according to etiology (embolism, thrombosis, graft thrombosis, and dissection groups) to assess survival, limb salvage, and freedom from re-intervention rates. Results: The mean age at onset was 72±15 years. The median follow-up length was 2.90 years. The Rutherford categories I, IIa, IIb, and III included 1, 38, 51, and 3 cases, respectively. Thromboembolectomy was performed in all patients in the embolism and thrombosis groups. In addition, endovascular treatment was performed in 25 (37.3%) patients, especially in the thrombosis group (81.3%). A major amputation could not be avoided in 10 patients. The 5-year limb salvage rates for categories IIa and IIb were 97.1% and 83.1%, respectively. The 5-year freedom from re-intervention rate was 89.2%. The survival rates at 1, 3, and 5 years were 87.9%, 75.2%, and 60.6%, respectively. Conclusion: The 5-year survival rates of patients with ALI were equivalent to those with chronic limb threatening ischemia (CLTI). The intervention and long-term outcomes were distinguishable according to etiology.
Collapse
Affiliation(s)
- Michihisa Umetsu
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Daijirou Akamatsu
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Hitoshi Goto
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Masato Ohara
- Department of Surgery, Japanese Red Cross Ishinomaki Hospital, Ishinomaki, Miyagi, Japan
| | - Munetaka Hashimoto
- Department of Surgery, Iwate Prefectural Isawa Hospital, Ohshu, Iwate, Japan
| | - Takuya Shimizu
- Division of Cardiovascular Surgery, Tohoku Medical and Pharmaceutical University Hospital, Sendai, Miyagi, Japan
| | - Hirofumi Sugawara
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Ken Tsuchida
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yoshitaro Yoshida
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Yuta Tajima
- Department of Surgery, Osaki Citizen Hospital, Osaki, Miyagi, Japan
| | - Shunya Suzuki
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Shinichiro Horii
- Division of Vascular Surgery, Department of Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Tetsuo Watanabe
- Department of Cardiovascular Surgery, Sendai City Hospital, Sendai, Miyagi, Japan
| | - Shigehito Miyagi
- Department of Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Hospital, Sendai, Miyagi, Japan
| |
Collapse
|
22
|
Holscher CM, Canner JK, Garonzik Wang JM, Abularrage CJ, Black JH, Hicks CW. Temporal trends and hospital costs associated with an endovascular-first approach for acute limb ischemia. J Vasc Surg 2019; 70:1506-1513.e1. [PMID: 31068269 DOI: 10.1016/j.jvs.2019.01.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 01/20/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Recent studies suggest similar perioperative outcomes for endovascular and open surgical management of acute limb ischemia (ALI). We sought to describe temporal trends, patient factors, and hospital costs associated with contemporary ALI management. METHODS We used the weighted National Inpatient Sample to estimate primary ALI cases requiring open or endovascular intervention (2005-2014). We used multivariable regression models to examine temporal trends, patient factors, and hospital costs associated with endovascular-first vs open-first management. RESULTS Of 116,451 admissions for ALI during the study period, 35.2% were treated by an endovascular-first approach. The percentage of admissions managed with an endovascular-first approach increased over time (P < .001). Independent predictors of endovascular-first management included younger age, male sex, renal insufficiency, and more recent calendar year of admission (P ≤ .02), whereas patients who underwent fasciotomy, those with Medicaid, and those admitted on a weekend were more likely to undergo open-first management (P ≤ .02). Endovascular-first management had higher mean hospital costs than open-first management ($29,719 vs $26,193; P < .001). After adjustment for patient, hospital, and admission characteristics, there was an increase of $981 in treatment costs per year in the endovascular-first group (95% confidence interval [CI], $571-$1392; P < .001), whereas the costs associated with an open-first approach remained relatively stable over time ($10 per year; 95% CI, -$295 to $315; P = .95; P < .001 for interaction). The risk-adjusted odds of in-hospital major amputation was similar in both groups (adjusted odds ratio, 0.99; 95% CI, 0.85-1.15; P = .88). CONCLUSIONS Use of an endovascular-first approach for the treatment of ALI has significantly increased over time. Although major amputation rates are similar for both approaches, the costs associated with an endovascular-first approach are increasing over time, whereas the costs of open surgery have remained stable. The cost-effectiveness of modern ALI management warrants further investigation.
Collapse
Affiliation(s)
- Courtenay M Holscher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research (JSCOR), Johns Hopkins University School of Medicine, Baltimore, Md
| | | | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, Md.
| |
Collapse
|
23
|
|
24
|
Liang S, Zhou L, Ye K, Lu X. Limb Salvage After Percutaneous Mechanical Thrombectomy in Patients with Acute Lower Limb Ischemia: A Retrospective Analysis from Two Institutions. Ann Vasc Surg 2019; 58:151-159. [PMID: 30769064 DOI: 10.1016/j.avsg.2018.11.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/01/2018] [Accepted: 11/11/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND To evaluate the short-term outcomes of percutaneous mechanical thrombectomy (PMT) in patients with acute lower limb ischemia (ALI) and to analyze the effect of ALI of different etiologies on the limb salvage. MATERIALS AND METHODS From January 2015 to December 2017, a retrospective analysis was performed on 112 patients (mean age: 66.5 years; 117 limbs in total; 66 limbs in 61 males) with ALI treated with PMT at 2 vascular institutions. Of the 117 limbs, 44 (41 patients) had acute arterial embolism, 36 (34 patients) had acute arterial thrombosis, and 37 (37 patients) had acute stent (31 limbs in 31 patients) or graft (6 limbs in 6 patients) thrombosis. The primary end point was limb salvage rate, and subgroups were analyzed by etiological factors. The secondary end points included patency rates, major bleeding complications, 30-day mortality, and reintervention rates. RESULTS The 30-day mortality rate was 3.6%. The incidence of major bleeding complications was 2.7%. During the follow-up, the limb salvage rates at 1 year and 2 years were 83.8% and 74.7%, respectively. Subgroup analysis showed that the limb salvage rate in patients with acute arterial embolism was 92.9% at 2 years after PMT, which was higher than that in patients with acute arterial thrombosis (73.3%, P = 0.04, hazard ratio [HR]: 3.6, 95% confidence interval [CI]: 1.1-11.7) and acute stent/graft thrombosis (62.5%, P = 0.01, HR: 4.7, 95% CI: 1.5-13.6). CONCLUSIONS PMT in patients with ALI is effective in preventing amputations over the 3-year study period with a reasonable safety profile, especially in patients with acute arterial embolism.
Collapse
Affiliation(s)
- Siyuan Liang
- Department of Vascular Surgery, Taizhou Municipal Hospital, Taizhou, Zhejiang, China
| | - Long Zhou
- Department of Vascular Surgery, Taizhou Municipal Hospital, Taizhou, Zhejiang, China
| | - Kaichuang Ye
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| |
Collapse
|
25
|
Vorwerk D, Triebe S, Ziegler S, Ruppert V. Percutaneous Mechanical Thromboembolectomy in Acute Lower Limb Ischemia. Cardiovasc Intervent Radiol 2018; 42:178-185. [DOI: 10.1007/s00270-018-2129-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 11/19/2018] [Indexed: 11/30/2022]
|
26
|
Thrombolysis in Acute Lower Limb Ischemia: Review of the Current Literature. Ann Vasc Surg 2018; 52:255-262. [DOI: 10.1016/j.avsg.2018.02.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 02/19/2018] [Accepted: 02/21/2018] [Indexed: 11/21/2022]
|
27
|
Prouse AF, Langner P, Plomondon ME, Ho PM, Valle JA, Barón AE, Armstrong EJ, Waldo SW. Temporal trends in the management and clinical outcomes of lower extremity arterial thromboembolism within a national Veteran population. Vasc Med 2018; 24:41-49. [PMID: 30105938 DOI: 10.1177/1358863x18793210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Lower extremity arterial thromboembolism is associated with significant morbidity and mortality. We sought to establish temporal trends in the incidence, management and outcomes of lower extremity arterial thromboembolism within the Veterans Affairs Healthcare System (VAHS). We identified patients admitted to VAHS between 2003 and 2014 with a primary diagnosis of lower extremity arterial thromboembolism. Medical and procedural management were ascertained from pharmaceutical and administrative data. Subsequent rates of major adverse limb events (MALE), major adverse cardiovascular events (MACE), and mortality were calculated using Cox proportional hazards models. From 2003 to 2014, there were 10,636 patients hospitalized for lower extremity thromboembolism across 140 facilities, of which 8474 patients had adequate comorbid information for analysis. Age-adjusted incidence decreased from 7.98 per 100,000 patients (95% CI: 7.28-8.75) in 2003 to 3.54 (95% CI: 3.14-3.99) in 2014. On average, the likelihood of receiving anti-platelet or anti-thrombotic therapy increased 2.3% (95% CI: 1.2-3.4%) per year during this time period and the likelihood of undergoing endovascular revascularization increased 4.0% (95% CI: 2.7-5.4%) per year. Clinical outcomes remained constant over time, with similar rates of MALE, MACE and mortality at 1 year after adjustment. In conclusion, the incidence of lower extremity arterial thromboembolism is decreasing, with increasing utilization of anti-thrombotic therapies and endovascular revascularization among those with this condition. Despite this evolution in management, patients with lower extremity thromboembolism continue to experience high rates of amputation and death within a year of the index event.
Collapse
Affiliation(s)
- Andrew F Prouse
- 1 Department of Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA
| | - Paula Langner
- 2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Mary E Plomondon
- 2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - P Michael Ho
- 2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Javier A Valle
- 1 Department of Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA.,2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Anna E Barón
- 2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Ehrin J Armstrong
- 1 Department of Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA.,2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| | - Stephen W Waldo
- 1 Department of Medicine, Division of Cardiology, University of Colorado, Aurora, CO, USA.,2 Department of Medicine, Division of Cardiology, VA Eastern Colorado Healthcare System, Denver, CO, USA
| |
Collapse
|
28
|
Early Outcomes following Endovascular, Open Surgical, and Hybrid Revascularization for Lower Extremity Acute Limb Ischemia. Ann Vasc Surg 2018. [DOI: 10.1016/j.avsg.2017.12.025] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
29
|
Shimada T, Urasawa K, Haraguchi T, Kitani S, Tan M, Koshida R, Igarashi Y, Sato K. Thrombectomy Using Myocardial Biopsy Forceps in Acute Limb Ischemia Patients. J Vasc Interv Radiol 2018; 29:1174-1179. [PMID: 29887182 DOI: 10.1016/j.jvir.2018.02.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 02/10/2018] [Accepted: 02/19/2018] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To evaluate the efficacy and safety of thrombectomy using myocardial biopsy forceps for the treatment of acute limb ischemia (ALI). MATERIALS AND METHODS A retrospective review of 11 ALI patients (12 affected limbs, 18 affected vessels) who underwent thrombectomy using biopsy forceps between November 2011 and April 2016 was performed. Of the 12 affected limbs, 2 limbs had stent thrombosis, 1 limb had thrombotic occlusion at a de novo stenosis site, and 9 limbs had embolic ALI. Biopsy forceps were used for angiographically limited arterial flow that persisted after the use of an aspiration catheter and conventional balloon angioplasty. The general technique for use of the biopsy forceps included advancement in parallel to a guidewire to the thrombus site, grasping of the thrombus with the forceps, and confirmation of grasping the thrombus with injection of a contrast medium prior to thrombus extraction. RESULTS Partial or total retrieval of the thrombus was angiographically confirmed in 12 of the 18 affected vessels, with restoration of normal blood flow in 11 vessels. Unsuccessful results in the remaining 6 affected vessels appeared to be due to friction at the aortoiliac bifurcation caused by the contralateral approach, small vessel size, or curvature of the anterior tibial artery. None of the 18 treated vessels had any complications such as dissection or perforation of the target vessel wall and distal emboli. None of the surviving patients required major or minor amputation. CONCLUSIONS Thrombectomy using biopsy forceps is a feasible technique for removal of an arterial thrombus in patients with ALI.
Collapse
Affiliation(s)
- Takenobu Shimada
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan; Department of Cardiology, Kurashiki Central Hospital, Okayama, Japan.
| | - Kazushi Urasawa
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
| | - Takuya Haraguchi
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
| | - Shunsuke Kitani
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
| | - Michinao Tan
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
| | - Ryoji Koshida
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
| | - Yasumi Igarashi
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
| | - Katsuhiko Sato
- Cardiovascular Center, Tokeidai Memorial Hospital, 2-3 Higashi 1 Kita 1 Chuo-ku, Sapporo, Hokkaido 060-0031, Japan
| |
Collapse
|
30
|
Inagaki E, Farber A, Kalish JA, Eslami MH, Siracuse JJ, Eberhardt RT, Rybin DV, Doros G, Hamburg NM. Outcomes of Peripheral Vascular Interventions in Select Patients With Lower Extremity Acute Limb Ischemia. J Am Heart Assoc 2018; 7:JAHA.116.004782. [PMID: 29650705 PMCID: PMC6015405 DOI: 10.1161/jaha.116.004782] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Contemporary data on patients presenting with acute limb ischemia (ALI), who are selected for treatment with endovascular peripheral vascular interventions (PVI), are limited. Our study examined outcomes following endovascular PVI in patients with ALI by comparing with patients treated for chronic critical limb ischemia using a regional quality improvement registry. Methods and Results Of the 11 035 patients in the Vascular Study Group of New England PVI database (2010–2014), we identified 365 patients treated for lower extremity ALI who were 5:1 frequency matched (by procedure year and arterial segments treated) to 1808 patients treated for critical limb ischemia. ALI patients treated with PVI had high burden of atherosclerotic risk factors and were more likely to have had prior ipsilateral revascularizations. ALI patients were less likely to be treated with self‐expanding stents and more likely to undergo thrombolysis than patients with critical limb ischemia. In multivariable analysis, ALI was associated with higher technical failure (odds ratio 1.7, 95% confidence interval, 1.1%–2.5%), increased rate of distal embolization (odds ratio 2.7, 95% confidence interval, 1.5%–4.9%), longer length of stay (means ratio 1.6, 95% confidence interval, 1.4%–1.8%), and higher in‐hospital mortality (odds ratio 2.8, 95% confidence interval, 1.3%–5.9%). ALI was not associated with risk of major amputation or mortality at 1 year. Conclusions In a multicenter cohort of patients treated with PVI, we found that ALI patients selected for treatment with endovascular techniques experienced greater short‐term adverse events but similar long‐term outcomes as their critical limb ischemia counterparts. Further studies are needed to refine the selection of ALI patients who are best served by PVI.
Collapse
Affiliation(s)
- Elica Inagaki
- Department of Surgery, Boston Medical Center, Boston, MA
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston, MA
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston, MA
| | - Mohammad H Eslami
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston, MA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston Medical Center, Boston, MA
| | - Robert T Eberhardt
- Evans Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA
| | - Denis V Rybin
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Gheorghe Doros
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
| | - Naomi M Hamburg
- Evans Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA
| | | |
Collapse
|
31
|
Acute Limb Ischemia Secondary to Native Artery Occlusion: Results of a Contemporary Case Series. World J Surg 2018; 42:2674-2681. [PMID: 29404750 DOI: 10.1007/s00268-018-4511-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The treatment of acute limb ischemia (ALI) has barely changed over the last years. However, the progressive implementation of anticoagulants, antiplatelet agents or statins within the population might have modified the profile and prognosis of patients suffering an ALI. The aim of this study was to evaluate the current results of the management of ALI secondary to a native artery occlusion. METHODS Retrospective study of 220 consecutive patients (mean age 78 years; 49% male) was conducted between 2007 and 2015. ALI secondary to trauma or grafts/stents occlusions were excluded. Statistical analysis was performed with logistic regression. RESULTS A total of 141 cases (64.1%) were attributed to embolism and 79 (35.9%) to acute arterial thrombosis. Peripheral neuro-ischemic impairment occurred in 135 patients (61.4%), being severe in 42 (19.1%). ALI treatment included anticoagulation (n = 27; 12.3%), regional fibrinolysis (n = 2; 1%), embolectomy/thrombectomy (n = 129; 58.6%), angioplasty/stenting (n = 8; 3.6%), bypass (n = 47; 21.3%) or direct major limb amputation (n = 7; 3.2%). Limb salvage and survival rates at 30/90 days were 95%/95% and 82.3%/74.1%, respectively. Independent risk factors for major amputation were diabetes, severe neuro-ischemic impairment, acute arterial thrombosis and treatment delay >1 day after vascular consultation. In addition, age, chronic peripheral arterial disease, any neuro-ischemic impairment and a hospitalization for any other reason simultaneous to the ALI were independently associated with mortality. CONCLUSIONS Regardless of excellent limb salvage rates, patients currently suffering from an ALI are, when compared to previous studies, older than before and with an increased rate of mortality. Risk factors do not appear to be modifiable once the ALI appears so prevention strategies should be aimed to avoid the episode.
Collapse
|
32
|
Gandhi SS, Ewing JA, Cooper E, Chaves JM, Gray BH. Comparison of Low-Dose Catheter-Directed Thrombolysis with and without Pharmacomechanical Thrombectomy for Acute Lower Extremity Ischemia. Ann Vasc Surg 2018; 46:178-186. [DOI: 10.1016/j.avsg.2017.07.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 11/25/2022]
|
33
|
Nagato H, Toma M, Yoshizawa K, Ohno N, Yoshikawa E. A Simple Reproducible Method to Treat Acute or Subacute Arterial Obstruction When the Thrombus Is Adherent to the Arterial Wall. Ann Vasc Dis 2017. [PMID: 29515710 PMCID: PMC5835427 DOI: 10.3400/avd.cr.17-00058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We report three consecutive patients with limb ischemia, where symptoms appeared several days to weeks prior to presentation. In all cases, initial over-the-wire thrombectomy failed due to adherence of the thrombus to the arterial wall. We adopted a new approach of stretching the whole obstructed segment by a series of ballooning using a percutaneous transluminal angioplasty (PTA) catheter. A subsequent thrombectomy was successful in all three cases. No further intervention, such as stenting or bypass surgery, was required. The adhering thrombus was dissected by stretching the arterial wall at the site of obstruction.
Collapse
Affiliation(s)
- Hisao Nagato
- Department of Cardiovascular Surgery, Kinki University Nara Hospital, Ikoma, Nara, Japan
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Kousuke Yoshizawa
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Nobuhisa Ohno
- Department of Cardiovascular Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo, Japan
| | - Eiji Yoshikawa
- Department of Cardiovascular Surgery, Japanese Red Cross Osaka Hospital, Osaka, Japan
| |
Collapse
|
34
|
Lukasiewicz A, Flisinski P, Lichota W. Catheter-directed thrombolysis is not limited to acute limb ischemia treatment: experience from a division of vascular surgery. THE JOURNAL OF CARDIOVASCULAR SURGERY 2017; 61:200-207. [PMID: 28849898 DOI: 10.23736/s0021-9509.17.10023-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Thrombolytic treatment has many potential indications in the era of modern vascular surgery. We aimed to analyze the contemporary experience in the catheter-directed, intraarterial thrombolysis in different clinical scenarios. METHODS The available data of 121 patients with different types (acute, subacute, complications of vascular procedures) of lower limb ischemia treated by means of the intraarterial, catheter-directed thrombolysis between November 2011 and December 2016 were retrospectively analyzed. The basic treatment protocol, utilized in 92% of patients, was a catheter-directed infusion of 40 mg of alteplase within 3.5 hours. Pre- and intraprocedural factors (indications, demographic details, comorbidities, the dose of alteplase utilized, underlying lesions procedures), as well as postoperative outcomes (lysis grade, death, complications, reinterventions, and limb loss after 1-month observation), were analyzed. RESULTS Successful thrombolysis was achieved in 76.1% (92 of 121) patients. The success rate was similar for acute, subacute limb ischemia and thrombotic complications of vascular procedures. Around 67.8% of patients (N.=82) had procedures to correct underlying lesions performed. Overall complication rate was 28.1%, but the major bleeding was observed in only 5% (6 patients). Neither intracranial bleeding nor gastrointestinal bleeding occurred. No mortality, 1.7% reintervention rate and 10.7% amputation rate were recorded during one-month follow-up. CONCLUSIONS Accelerated intraarterial thrombolysis is an effective measure in the treatment of acute, sub-acute limb ischemia as well as thromboembolic complications of vascular procedures. It carries a low risk of major bleeding. The location of thrombus in the crural arteries adversely affects the treatment results. Atrial fibrillation increases the risk of amputation while complete thrombus lysis is protective.
Collapse
Affiliation(s)
| | - Piotr Flisinski
- Department of Vascular Surgery, Regional Specialty Hospital, Grudziadz, Poland.,Department of Normal Anatomy, Nicolaus Copernicus University, Collegium Medicum, Bydgoszcz, Poland
| | - Wojciech Lichota
- Department of Vascular Surgery, Regional Specialty Hospital, Grudziadz, Poland
| |
Collapse
|
35
|
Davies MG, El-Sayed HF. Outcomes of native superficial femoral artery chronic total occlusion recanalization after failed femoropopliteal bypass. J Vasc Surg 2017; 65:726-733. [DOI: 10.1016/j.jvs.2016.09.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 09/19/2016] [Indexed: 11/15/2022]
|
36
|
Majka M, Gadda G, Taibi A, Gałązka M, Zieliński P. Earliest effects of sudden occlusions on pressure profiles in selected locations of the human systemic arterial system. Phys Rev E 2017; 95:032414. [PMID: 28415274 DOI: 10.1103/physreve.95.032414] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Indexed: 06/07/2023]
Abstract
We have developed a numerical simulation method for predicting the time dependence (wave form) of pressure at any location in the systemic arterial system in humans. The method uses the matlab-Simulink environment. The input data include explicitly the geometry of the arterial tree, treated up to an arbitrary bifurcation level, and the elastic properties of arteries as well as rheological parameters of blood. Thus, the impact of anatomic details of an individual subject can be studied. The method is applied here to reveal the earliest stages of mechanical reaction of the pressure profiles to sudden local blockages (thromboses or embolisms) of selected arteries. The results obtained with a purely passive model provide reference data indispensable for studies of longer-term effects due to neural and humoral mechanisms. The reliability of the results has been checked by comparison of two available sets of anatomic, elastic, and rheological data involving (i) 55 and (ii) 138 arterial segments. The remaining arteries have been replaced with the appropriate resistive elements. Both models are efficient in predicting an overall shift of pressure, whereas the accuracy of the 55-segment model in reproducing the detailed wave forms and stabilization times turns out dependent on the location of the blockage and the observation point.
Collapse
Affiliation(s)
- Marcin Majka
- Institute of Nuclear Physics Polish Academy of Sciences, ulica Radzikowskiego 152, PL-31342 Cracow, Poland
- University of Ferrara, Department of Physics and Earth Sciences, Via Saragat 1, 44122 Ferrara, Italy
| | - Giacomo Gadda
- University of Ferrara, Department of Physics and Earth Sciences, Via Saragat 1, 44122 Ferrara, Italy
| | - Angelo Taibi
- University of Ferrara, Department of Physics and Earth Sciences, Via Saragat 1, 44122 Ferrara, Italy
| | - Mirosław Gałązka
- Institute of Nuclear Physics Polish Academy of Sciences, ulica Radzikowskiego 152, PL-31342 Cracow, Poland
| | - Piotr Zieliński
- Institute of Nuclear Physics Polish Academy of Sciences, ulica Radzikowskiego 152, PL-31342 Cracow, Poland
| |
Collapse
|
37
|
Abstract
Acute limb ischemia is a vascular emergency, threatening the viability of the affected limb and requiring immediate recognition and treatment. Even with revascularization of the affected extremity, acute limb ischemia is associated with significant morbidity and mortality resulting in up to a 15% risk of amputation during the initial hospitalization and a 1 in 5 risk of mortality within 1 year of the index event. This review summarizes the current management of acute limb ischemia. Understanding the diagnosis and therapeutic options will aid clinicians in treating these critically ill patients.
Collapse
Affiliation(s)
- Javier A Valle
- Division of Cardiology, VA Eastern Colorado Healthcare System, University of Colorado, 1055 Clermont Street, Denver, CO 80220, USA
| | - Stephen W Waldo
- Division of Cardiology, VA Eastern Colorado Healthcare System, University of Colorado, 1055 Clermont Street, Denver, CO 80220, USA.
| |
Collapse
|
38
|
Urbak L, de la Motte L, Rørdam P, Siddiqi A, Sillesen H. Catheter-Directed Thrombolysis in the Treatment of Acute Ischemia in Lower Extremities Is Safe and Effective, Especially with Concomitant Endovascular Treatment. Ann Vasc Dis 2017; 10:125-131. [PMID: 29034038 PMCID: PMC5579780 DOI: 10.3400/avd.oa.16-00140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate the influence of pre-procedural characteristics on immediate and late results as well as the safety of catheter-directed thrombolysis (CDT) in acute ischemia of the lower extremity. Materials and Methods: A retrospective study comprising 249 patients treated by CDT from January 2006 to December 2012. Outcomes were primary patency, haemorrhagic complications, amputation and mortality. Results: Primary patency for CDT alone was 68%, for CDT plus endovascular treatment 87% and for successful CDT with supplementary surgery 62% giving an overall primary patency of 76%. Two (0.8%) patients suffered from cerebral haemorrhage during CDT. We found a significant correlation between 30 day amputation rate and no visual distal run-off at CDT start (OR 2.31; CI95% 1.09–4.91; p-value=0.02) and onset of symptoms to CDT start of 8–14 days (OR 4.09; CI95% 1.42–11.81; p-value=0.01). Lack of visualized distal run-off was also associated with a significant risk of 30 day mortality (OR 5.84; CI95% 1.26–27.00; p-value=0.02). Conclusion: Our results show that CDT is a feasible and safe treatment option especially when combined with angioplasty +/− stent. However, no distal run-off at primary angiography is associated with higher rates of amputation during follow-up and 30 day mortality.
Collapse
Affiliation(s)
- Lærke Urbak
- Department of Vascular Surgery, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Louise de la Motte
- Department of Vascular Surgery, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Peter Rørdam
- Department of Vascular Surgery, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Aamir Siddiqi
- Department of Vascular Interventional Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
39
|
Direct Stenting in Patients with Acute Lower Limb Arterial Occlusions: Immediate and Long-Term Results. Cardiovasc Intervent Radiol 2016; 40:192-201. [PMID: 27826790 DOI: 10.1007/s00270-016-1500-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The purpose of this study is to accentuate the efficacy of direct stenting (stent placement without predilatation of the lesion) in patients with acute lower limb arterial ischemia (ALLI). MATERIALS AND METHODS Between January 2010 and September 2015, 16 patients (11 men and 5 women) underwent direct stenting of acute arterial occlusions. All patients had contraindication for surgical revascularization or catheter-directed thrombolysis. According to SVS/ISCVS Classification, six patients had IIa and ten patients IIb ALLI. The occlusions were located in CIA, EIA, SFA, or popliteal artery. Mean follow-up time with clinical examination and color Duplex ultrasonography was 37.6 months (range 1-72). We analyzed the technical and clinical outcomes of the procedures, as well the complications and patency rates. RESULTS Technical success was achieved in all patients (16/16) and there was significant clinical improvement in 15 patients. There was neither distal embolization nor procedure-related complications. During the 6 years of follow-up, four patients died due to non-procedure-related causes and there were two minor and one major amputations. The primary patency rates and the amputation-free survival rates were 93.7 and 87% at 1 year, 75.2 and 71.2% at 3 years, and 75.2 and 62.3%, respectively, at 6 years. CONCLUSIONS Direct stenting may be a valuable alternative procedure for acute arterial occlusions in selected cases with high technical success and significant clinical improvement. LEVEL OF EVIDENCE Level 4, Case Series.
Collapse
|
40
|
Long-Term Outcomes of Catheter-Directed Thrombolysis for Acute Lower Extremity Occlusions of Native Arteries and Prosthetic Bypass Grafts. Ann Vasc Surg 2016; 31:134-42. [DOI: 10.1016/j.avsg.2015.08.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 08/23/2015] [Accepted: 08/29/2015] [Indexed: 11/18/2022]
|
41
|
Arsicot M, Della Schiava N, Boudjelit T, Rouvière O, Feugier P, Lermusiaux P, Millon A. Acute Ischemia due to Superficial Femoral Artery Thrombosis: Results of In Situ Fibrinolysis. Ann Vasc Surg 2016; 33:31-8. [PMID: 26806234 DOI: 10.1016/j.avsg.2015.10.029] [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: 07/03/2015] [Revised: 09/25/2015] [Accepted: 10/11/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND The management of acute ischemia due to the thrombosis superficial femoral artery (SFA) stents is complex. In situ arterial fibrinolysis, still not evaluated in this indication, would allow, by lifting the ischemia and uncovering its cause, to avoid thrombectomy, endovascular recanalization, or arterial bypass. The purpose of the study was to evaluate the effectiveness, the complications, and the assisted secondary patency of in situ fibrinolysis for thrombosis of SFA stents. METHODS We conducted a retrospective monocentric study with prospective collection of the data. Between October 2011 and December 2014, 86 in situ fibrinolysis procedures were carried out for acute lower limb ischemia. Twelve procedures were carried out for acute ischemia due to the thrombosis of SFA stents. Clinical success was defined by the lifting of acute ischemia. The causes of thromboses, the complications related to the fibrinolysis, and the secondary assisted patency were analyzed. RESULTS The mean age of the patients was 66.3 (55-90) years. The average length of the stents was 119.3 (18-270) mm. In 10 patients, the thrombosis extended in the full length of the artery. The average time between the implantation of the stent and the initiation of the fibrinolysis was 180 (11-369) days. The average time between the beginning of the symptoms and fibrinolysis was 5 (0-12) days. The average duration of treatment was 46 (24-72) hr. Clinical success was obtained in all the patients. Diagnosed isolated or associated lesions were a progression of the atheromatous disease upstream or downstream of the stent in 6 cases, and an isolated intrastent restenosis in 3 cases. In 2 cases, no obvious cause was found. One or more additional endovascular procedures were carried out in 9 cases at the end of the fibrinolysis, and consisted of a transluminal intrastent angioplasty with an active balloon in 5 cases, an additional stenting in 3 cases, and the stenting of upstream or downstream arteries in 5 cases. Secondary assisted patency was 100% at 5 months. No major hemorrhagic complication was observed. Two false aneurysms at the site of femoral puncture were observed. CONCLUSION Our results suggest that ischemia due to the thrombosis of SFA stents can be dealt with first intention in situ fibrinolysis which allows the endovascular treatment of the causal lesion, thus avoiding thrombectomy or bypass.
Collapse
Affiliation(s)
- Matthieu Arsicot
- Service de chirurgie vasculaire, Etablissement Edouard Herriot, Hospices Civils de Lyon, Lyon, France.
| | - Nellie Della Schiava
- Service de chirurgie vasculaire, Etablissement Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Tarek Boudjelit
- Service de chirurgie vasculaire, Etablissement Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Olivier Rouvière
- Service de Radiologie, Etablissement Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Patrick Feugier
- Service de chirurgie vasculaire, Etablissement Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Patrick Lermusiaux
- Service de chirurgie vasculaire, Etablissement Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Antoine Millon
- Service de chirurgie vasculaire, Etablissement Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| |
Collapse
|
42
|
Wang JC, Kim AH, Kashyap VS. Open surgical or endovascular revascularization for acute limb ischemia. J Vasc Surg 2015; 63:270-8. [PMID: 26603542 DOI: 10.1016/j.jvs.2015.09.055] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 09/28/2015] [Indexed: 10/22/2022]
Abstract
Acute limb ischemia (ALI) is one of the most common vascular emergencies, with high risk for limb loss if it is not treated expediently. Endovascular therapy is less invasive and used increasingly because of patient factors that disfavor open surgery despite limited quality data to support its safety and efficacy. This evidence summary reviews literature from 1990 to 2014, comparing contemporary surgical and endovascular revascularization. Systematic review was performed with emphasis on acuity of presentation, study design, revascularization techniques, limb salvage and mortality rates, and complications. There were 2999 articles identified and 563 abstracts reviewed; 68 articles were reviewed fully and 26 critically appraised. Limb salvage, amputation-free survival, overall survival and mortality, and treatment complications were elucidated, including Medicare outcomes data. Risk factors for amputation and mortality were identified. Surgical or endovascular revascularization for ALI is achievable with acceptable limb salvage and amputation rates, which are not markedly different between the two modalities in the short term. Endovascular therapy and surgery are complementary rather than competing strategies for ALI. Further good-quality clinical trial data are needed to define longer term outcomes.
Collapse
Affiliation(s)
- John C Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio.
| | - Ann H Kim
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Vikram S Kashyap
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University Hospitals Case Medical Center, Cleveland, Ohio
| |
Collapse
|
43
|
Risk Factors for Long-Term Mortality and Amputation after Open and Endovascular Treatment of Acute Limb Ischemia. Ann Vasc Surg 2015; 30:82-92. [PMID: 26560838 DOI: 10.1016/j.avsg.2015.10.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 10/01/2015] [Accepted: 10/27/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Acute limb ischemia (ALI) is a highly morbid and fatal vascular emergency with little known about contemporary, long-term patient outcomes. The goal was to determine predictors of long-term mortality and amputation after open and endovascular treatment of ALI. METHODS A retrospective review of ALI patients at a single institution from 2005 to 2011 was performed to determine the impact of revascularization technique on 5-year mortality and amputation. For each main outcome 2 multivariable models were developed; the first adjusted for preoperative clinical presentation and procedure type, the second also adjusted for postoperative adverse events (AEs). RESULTS A total of 445 limbs in 411 patients were treated for ALI. Interventions included surgical thrombectomy (48%), emergent bypass (18%), and endovascular revascularization (34%). Mean age was 68 ± 15 years, 54% were male, and 23% had cancer. Most patients presented with Rutherford classification IIa (54%) or IIb (39%). The etiology of ALI included embolism (27%), in situ thrombosis (28%), thrombosed bypass grafts (32%), and thrombosed stents (13%). Patients treated with open procedures had significantly more advanced ischemia and higher rates of postoperative respiratory failure, whereas patients undergoing endovascular interventions had higher rates of technical failure. Rates of postprocedural bleeding and cardiac events were similar between both treatments. Excluding Rutherford class III patients (n = 12), overall 5-year mortality was 54% (stratified by treatment, 65% for thrombectomy, 63% for bypass, and 36% for endovascular, P < 0.001); 5-year amputation was 28% (stratified by treatment, 18% for thrombectomy, 27% for bypass, and 17% for endovascular, P = 0.042). Adjusting for comorbidities, patient presentation, AEs, and treatment method, the risk of mortality increased with age (hazard ratio [HR] = 1.04, P < 0.001), female gender (HR = 1.50, P = 0.031), cancer (HR = 2.19, P < 0.001), fasciotomy (HR = 1.69, P = 0.204) in situ thrombosis or embolic etiology (HR = 1.73, P = 0.007), cardiac AEs (HR = 2.25, P < 0.001), respiratory failure (HR = 2.72, P < 0.001), renal failure (HR = 4.70, P < 0.001), and hemorrhagic events (HR = 2.25, P = 0.003). Risk of amputation increased with advanced ischemia (Rutherford IIb compared with IIa, HR = 2.57, P < 0.001), thrombosed bypass etiology (HR = 3.53, P = 0.002), open revascularization (OR; HR = 1.95, P = 0.022), and technical failure of primary intervention (HR = 6.01, P < 0.001). CONCLUSIONS After the treatment of ALI, long-term mortality and amputation rates were greater in patients treated with open techniques; OR patients presented with a higher number of comorbidities and advanced ischemia, while also experiencing a higher rate of major postoperative complications. Overall, mortality rates remained high and were most strongly associated with baseline comorbidities, acuity of presentation, and perioperative AEs, particularly respiratory failure. Comparatively, amputation risk was most highly associated with advanced ischemia, thrombosed bypass, and failure of the initial revascularization procedure.
Collapse
|
44
|
Lee K, Istl A, Dubois L, DeRose G, Forbes TL, Wiseman D, Mujoomdar A, Kribs S, Power AH. Fibrinogen Level and Bleeding Risk During Catheter-Directed Thrombolysis Using Tissue Plasminogen Activator. Vasc Endovascular Surg 2015; 49:175-9. [PMID: 26462979 DOI: 10.1177/1538574415611234] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this study was to determine whether low fibrinogen levels (fibrinogen level <1.5 g/L) during catheter-directed thrombolysis are associated with an increased bleeding risk. METHODS A retrospective review was performed on patients undergoing extremity arterial or venous thrombolysis between 2005 and 2013. RESULTS Patients in the low fibrinogen group were younger (P = .006) and had a higher number of venous occlusive events (P = .004). The low fibrinogen group received a larger dose of tissue plasminogen activator (tPA; P = .009) and had a longer duration of thrombolysis (P = .010). The rates of major bleeding were not significantly different (P = .139). Univariate analysis showed that larger total dose and longer duration of tPA infusion were associated with increased bleeding complications (P < .01 and P = .03). CONCLUSION A fibrinogen level <1.5 g/L during thrombolysis was not associated with an increased bleeding risk. However, larger dose and longer duration of thrombolysis were associated with increased bleeding risk.
Collapse
Affiliation(s)
- Kevin Lee
- Division of Vascular Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Alexandra Istl
- Division of Vascular Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Luc Dubois
- Division of Vascular Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Guy DeRose
- Division of Vascular Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Daniele Wiseman
- Division of Interventional Radiology, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Amol Mujoomdar
- Division of Interventional Radiology, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Stewart Kribs
- Division of Interventional Radiology, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Adam H Power
- Division of Vascular Surgery, London Health Sciences Centre, Western University, London, Ontario, Canada
| |
Collapse
|
45
|
Leung DA, Blitz LR, Nelson T, Amin A, Soukas PA, Nanjundappa A, Garcia MJ, Lookstein R, Simoni EJ. Rheolytic Pharmacomechanical Thrombectomy for the Management of Acute Limb Ischemia. J Endovasc Ther 2015; 22:546-57. [PMID: 26109628 DOI: 10.1177/1526602815592849] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To present the results of rheolytic pharmacomechanical thrombectomy (PMT) for the management of acute limb ischemia (ALI) as reported in the PEARL Registry ( PEripheral Use of AngioJet Rheolytic Thrombectomy with a variety of catheter Lengths). Methods: A total of 283 patients (mean age 65±13 years; 170 men) presenting with ALI undergoing treatment with the AngioJet System at participating institutions were enrolled in the registry. Rutherford ALI categories included 26% with viable limbs, 38% with marginally threatened limbs, 35% with immediately threatened limbs, and <1% with irreversible damage. Procedure and follow-up data were collected for the calculation of outcomes. To control for patient selection bias, propensity score matching was used to compare outcomes for patients undergoing PMT with or without catheter-directed thrombolysis (CDT). Results: Procedure success was achieved in 235 (83%) of 283 patients. Half of the procedures (147, 52%) were completed without the need for adjunctive CDT. At 12-month follow-up, amputation-free survival and freedom from mortality were 81% and 91%, respectively; 12-month freedom from bleeding requiring transfusion was 91%, and freedom from renal failure was 95%. Subgroup analysis revealed significantly better outcomes in patients without infrapopliteal involvement and those who underwent PMT without CDT. In the matched cohorts, higher rates of procedure success, 12-month amputation-free survival, and 12-month freedom from amputation were observed in the PMT without CDT group (88% vs 74%, p=0.021; 87% vs 72%, p=0.028; 96% vs 81%, p=0.01, respectively). Conclusions: The results support the use of PMT as a first-line treatment for ALI, providing a rapid reperfusion to the extremity, reduced procedure time, and an acceptable risk profile without compromising limb salvage.
Collapse
Affiliation(s)
| | | | | | - Ali Amin
- Reading Hospital & Medical Center, West Reading, PA, USA
| | | | | | | | | | - Eugene J. Simoni
- Pennsylvania State University and the Milton S. Hershey Medical Center, Hershey, PA, USA
| |
Collapse
|
46
|
Taha AG, Byrne RM, Avgerinos ED, Marone LK, Makaroun MS, Chaer RA. Comparative effectiveness of endovascular versus surgical revascularization for acute lower extremity ischemia. J Vasc Surg 2015; 61:147-54. [DOI: 10.1016/j.jvs.2014.06.109] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Accepted: 06/23/2014] [Indexed: 11/28/2022]
|
47
|
|
48
|
Kuoppala M, Åkeson J, Acosta S. Outcome after thrombolysis for occluded endoprosthesis, bypasses and native arteries in patients with lower limb ischemia. Thromb Res 2014; 134:23-8. [DOI: 10.1016/j.thromres.2014.02.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 02/05/2014] [Accepted: 02/21/2014] [Indexed: 11/25/2022]
|
49
|
Chaer R. Successful outcomes with thrombolysis for limb ischemia with suprainguinal interventions, but high limb loss and mortality for infrainguinal disease. Thromb Res 2014; 134:9-10. [PMID: 24857232 DOI: 10.1016/j.thromres.2014.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 05/05/2014] [Accepted: 05/05/2014] [Indexed: 11/16/2022]
Affiliation(s)
- Rabih Chaer
- The University of Pittsburgh School of Medicine, Division of Vascular Surgery, A-1011 PUH/200 Lothrop St., Pittsburgh PA 15213.
| |
Collapse
|
50
|
Byrne RM, Taha AG, Avgerinos E, Marone LK, Makaroun MS, Chaer RA. Contemporary outcomes of endovascular interventions for acute limb ischemia. J Vasc Surg 2014; 59:988-95. [DOI: 10.1016/j.jvs.2013.10.054] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 10/03/2013] [Accepted: 10/06/2013] [Indexed: 10/25/2022]
|