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Jarosinski MC, Kennedy JN, Iyer S, Tzeng E, Eslami M, Sridharan ND, Reitz KM. Contemporary National Incidence and Outcomes of Acute Limb Ischemia. Ann Vasc Surg 2024:S0890-5096(24)00469-2. [PMID: 39067849 DOI: 10.1016/j.avsg.2024.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 05/02/2024] [Accepted: 06/02/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Acute limb ischemia (ALI) is a morbid and deadly diagnosis. However, existing epidemiologic studies describing ALI predate the introduction of the Affordable Care Act in 2010 and direct oral anticoagulants in 2011. Thus, we synergized the National Inpatient Sample (NIS) and United States Census to define contemporary trends in the incidence, treatment, and outcomes of ALI in the US. METHODS We included emergent admissions of adults with primary diagnosis of lower extremity ALI in survey-weighted NIS data (2005-2020). Mann-Kendal trend test evaluated ALI incidence (primary outcome), anticoagulation usage, insurance coverage, revascularization type, and in-hospital amputation/death. Multivariable logistic regression quantified covariate associations with in-hospital amputation/death. RESULTS Of the 582,322,862 estimated hospitalizations in the NIS, 227,440 met the inclusion criteria (mean age 68.80 years, 49.94% women, 76.66% White). ALI incidence peaked in 2006 (7.16/100,000 person-years) but has declined since 2015 to 4.16/100,000 person-years in 2020 (ptrend = 0.008). Endovascular revascularization, anticoagulation, and Medicaid coverage increased, while self-pay insurance decreased (ptrend < 0.05). Amputation rates significantly decreased from 8.04 to 6.54% (ptrend = 0.01) while death rate remained at 5.59% (ptrend = 0.16) over the study period. Prehospitalization anticoagulation was associated with decreased amputation (adjusted odds ratio [aOR] = 0.74 (95% confidence interval [CI] 0.65-0.84)) and death (aOR = 0.50 (95% CI 0.43-0.57)). When controlling for covariates, women had a higher risk of death (aOR = 1.17 (95% CI 1.07-1.27), P < 0.0001), while Black patients had a higher risk of amputation (aOR = 1.24 (95% CI 1.10-1.41), P < 0.0001). CONCLUSIONS Our US population based epidemiological study demonstrates that ALI incidence and in-hospital amputation rates are decreasing, while mortality remains unchanged. We further highlight the ongoing need for ALI investigation specifically as it relates to access to care, antithrombotic therapy use, treatment strategy, and strategies to combat gender and racial disparities.
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Affiliation(s)
| | - Jason N Kennedy
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stuthi Iyer
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mohammad Eslami
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
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Maldonado TS, Powell A, Wendorff H, Rowse J, Nagarsheth KH, Dexter DJ, Dietzek AM, Muck PE, Arko FR, Chung J. One-year limb salvage and quality of life following mechanical aspiration thrombectomy in patients with acute lower extremity ischemia. J Vasc Surg 2024:S0741-5214(24)01222-9. [PMID: 38914349 DOI: 10.1016/j.jvs.2024.05.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 05/17/2024] [Accepted: 05/20/2024] [Indexed: 06/26/2024]
Abstract
OBJECTIVE Lower extremity acute limb ischemia (LE-ALI) is associated with high morbidity and mortality rates, and a burden on patient quality of life (QoL). There is limited medium- to long-term evidence on mechanical aspiration thrombectomy (MT) in patients with LE-ALI. The STRIDE study was designed to assess safety and efficacy of MT using the Indigo Aspiration System in patients with LE-ALI. Thirty-day primary and secondary endpoints and additional outcomes were previously published. Here, we report 365-day secondary endpoints and QoL data from STRIDE. METHODS STRIDE was a multicenter, prospective, single-arm, observational cohort study that enrolled 119 patients across 16 sites in the United States and Europe. Patients were treated first-line with MT using the Indigo Aspiration System (Penumbra, Inc). The study completed follow-up in October 2023. Secondary endpoints at 365 days included target limb salvage and mortality. Additionally, the VascuQoL-6 questionnaire, developed for evaluating patient-centered QoL outcomes for peripheral arterial disease, was assessed at baseline and follow-up through 365 days. RESULTS Seventy-three percent of patients (87/119) were available for 365-day follow-up. Mean age of these patients was 65.0 ± 13.3 years, and 44.8% were female. Baseline ischemic severity was classified as Rutherford I in 12.6%, Rutherford IIa in 51.7%, and Rutherford IIb in 35.6%. In general, baseline and disease characteristics (demographics, medical history, comorbidities, target thrombus) of these patients are similar to the enrolled cohort of 119 patients. The secondary endpoints at 365 days for target limb salvage was 88.5% (77/87) and mortality rate was 12.0% (12/100). VascuQoL-6 improved across all domains, with a median total score improvement from 12.0 (interquartile range, 9.0-15.0) at baseline to 19.0 (interquartile range, 16.0-22.0) at 365 days. CONCLUSIONS These 365-day results from STRIDE demonstrate that first-line MT with the Indigo Aspiration System for LE-ALI portray continued high target limb salvage rates and improved patient-reported QoL. These findings indicate Indigo as a safe and effective therapeutic option for LE-ALI.
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Affiliation(s)
- Thomas S Maldonado
- Division of Vascular Surgery, NYU Langone Health, NYU Langone Medical Center, New York, NY.
| | | | | | - Jarrad Rowse
- University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | - Frank R Arko
- Sanger Heart and Vascular Institute, Charlotte, NC
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Huang H, Kong J, He X, Chen L, Su H. Nomogram for predicting amputation-free survival in acute lower limb ischemia patients treated by endovascular therapy. Heliyon 2024; 10:e32110. [PMID: 38867944 PMCID: PMC11168398 DOI: 10.1016/j.heliyon.2024.e32110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 05/20/2024] [Accepted: 05/28/2024] [Indexed: 06/14/2024] Open
Abstract
Objectives To develop a novel and accurate nomogram to predict survival without amputation in patients with acute lower limb ischemia (ALLI) during the first year following endovascular therapy. Methods Patients with ALLI who underwent endovascular therapy in our department between January 2012 and September 2020 were screened and included in the research. The included patients were randomly divided into a training and validation cohorts, respectively. Univariate and multivariate analyses were used in the training cohort to identify independent risk factors for amputation-free survival (AFS). A nomogram was then developed according to the identified independent risk factors. The nomogram was then validated in the validation cohort. Results 415 Chinese patients with 417 affected limbs were included in this study. Among these patients, 311 patients were classified into the training cohort and 104 patients were assigned to the validation cohort. Most patients were men (n = 240) and the average age of patients was 71.43 (standard deviation 8.86) years old. After the univariate and multivariate analyses, advanced age (p < 0.001), history of smoking (p < 0.001), atrial fibrillation (p < 0.001), and insufficient outflow (p = 0.001) were revealed as independent risk factors for AFS during the first year. The nomogram yielded AUROC values of 0.912 (95 % confidence interval [CI]: 0.873-0.950) and 0.889 (95 % CI: 0.812-0.967) in the training and validation cohorts, respectively. Conclusion Advanced age, history of smoking, atrial fibrillation, and insufficient outflow were independent negative predictors for AFS in ALLI patients treated by endovascular therapy. The novel nomogram offered an accurate prediction of AFS in ALLI patients.
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Affiliation(s)
- Hao Huang
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jie Kong
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xu He
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Liang Chen
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Haobo Su
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Torres Ruiz I, Ooi XY, Harry L, Koksoy C, Pallister ZS, Gilani R, Mills JL, Bailey CJ, Chung J. Multilevel thrombotic or embolic burden and its role in sex-related outcomes in acute limb ischemia. J Vasc Surg 2024:S0741-5214(24)01251-5. [PMID: 38871066 DOI: 10.1016/j.jvs.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVE The impact of sex upon outcomes in acute limb ischemia (ALI) remains disputed. We aim to quantify the effect of sex upon amputation-free survival (AFS) after a percutaneous-first approach for ALI. METHODS This was a two-center retrospective review of ALI managed via a percutaneous-first approach. Demographics, comorbidities, and clinical characteristics were analyzed. The Kaplan-Meier and Cox regression were used to estimate AFS, limb salvage, and overall survival. RESULTS Over 9 years, 170 patients (n = 87, 51% males; median age, 67 [interquartile range (IQR), 59-77 years) presented with ALI. Rutherford classification was I in 56 (33%); IIa in 85 (50%); IIb in 20 (12%), and III in 9 (5%). Thirty-day mortality, major amputation rate, and fasciotomy rates were 8% (n = 13); 6.5% (n = 11), and 4.7% (n = 8), respectively. Among revascularized limbs, 92% were patent at 30 days. Length of stay was 7 days (IQR, 3-11 days). Complications included 13 bleeding episodes (8%), four cases of atrial fibrillation (2%), and three re-thrombosis/clot extension events (1.7%). No differences were noted in complication rates when stratified by sex. Females were older than males (median age, 70 [IQR, 62-79] vs 65 [IQR, 56-76 years]; P = .02) and more likely to present with atrial fibrillation (20.5% vs 8%; P = .02) and hyperlipidemia (72% vs 57%; P = .04). Females also more frequently presented with multi-level thrombotic/embolic burden compared with males (56% vs 43%; P = .03) and required both aspiration thrombectomy and thrombolysis (27% vs 14%; P = .02). Kaplan-Meier estimated median AFS, limb salvage, and overall survival were 425 days (IQR, 140-824 days); 314 days (IQR, 72-727 days); and 342 days (IQR, 112-762 days). When stratified by sex, females had worse survival (median, 270 days [IQR, 92-636 days] vs 406 days [IQR, 140-937 days]; P = .005) and limb salvage (median, 241 days [IQR, 88-636 days] vs 363 days [IQR, 49-822 days]; P = .04) compared with males. Univariate Cox regression showed female sex (hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.04-2.05; P = .03), multi-level thrombotic/embolic burden (HR, 1.64; 95% CI, 1.17-2.31; P = .004), and Rutherford class (HR, 1.37; 95% CI, 1.08-1.73; P = .009) predicted major amputation/death. By multivariable Cox regression, multi-level thrombotic/embolic burden (HR, 1.54; 95% CI, 1.09-2.17; P = .01), Rutherford class (HR, 1.34; 95% CI, 1.07-1.69; P = .01), and female sex (HR, 1.45; 95% CI, 1.03-2.05; P = .03) were each independently predictive of major amputation/death. CONCLUSIONS A percutaneous-first strategy is safe and efficacious in the overall ALI population. Similar to prior works, female vs male patients with ALI in our cohort have higher rates of mortality and major amputation. In our multivariable model, multi-level thrombotic/embolic burden was independently associated with a greater than 45% increased hazard of major amputation/death at last follow-up. Further prospective analysis is warranted to elucidate the underlying factors contributing to the higher prevalence of multi-level thrombotic/embolic burden in female patients with ALI, and to further define the optimal percutaneous-first approach for ALI in consideration of patient sex and extent of clot burden.
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Affiliation(s)
- Ilse Torres Ruiz
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Xin Yee Ooi
- Baylor College of Medicine - School of Medicine, Houston, TX
| | - Lauren Harry
- Division of Vascular Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Cuneyt Koksoy
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Zachary S Pallister
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Ramyar Gilani
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Charles J Bailey
- Division of Vascular Surgery, University of South Florida Morsani College of Medicine, Tampa, FL
| | - Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
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Dobesh K, Natour AK, Kabbani LS, Rteil A, Lee A, Nypaver TJ, Weaver M, Shepard AD. Patients with Acute Lower Limb Ischemia Continue to Have Significant Morbidity and Mortality. Ann Vasc Surg 2024; 108:127-140. [PMID: 38848889 DOI: 10.1016/j.avsg.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 02/11/2024] [Accepted: 03/13/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND The treatment of acute lower limb ischemia (ALLI) has evolved over the last several decades with the availability of several new treatment modalities. This study was undertaken to evaluate the contemporary presentation and outcomes of ALLI patients. METHODS We retrospectively analyzed data from a prospectively collected database of all patients who presented to our tertiary referral hospital with acute ischemia of the lower extremity between May 2016 and October 2020. The cause of death was obtained from the Michigan State Death Registry. RESULTS During the study period, 233 patients (251 lower limbs) were evaluated for ALLI. Seventy-three percent had thrombotic occlusion, 24% had embolic occlusion, and 3% due to a low flow state. Rutherford classification of ischemia severity was 7%, 49%, 40%, and 4% for Rutherford grade I, IIA, IIB, and III, respectively. Five percent underwent primary amputations, and 6% received medical therapy only. The mean length of stay was 11 ± 9 days. Nineteen percent of patients were readmitted within 30 days of discharge. At 30 days postoperatively, mortality was 9% and limb loss was 19%. On multivariate analysis, 1 or no vessel runoff to the foot postoperatively was associated with higher 30-day limb loss. Patients with no run-off vessels postoperatively had significantly higher 30-day mortality. Cardiovascular complications accounted for most deaths (48%). At 1-year postoperatively, mortality and limb loss reached 17% and 34%, respectively. CONCLUSIONS Despite advances in treatment modalities and cardiovascular care, patients presenting with ALLI continue to have high mortality, limb loss, and readmission rates at 30 days.
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Affiliation(s)
- Kaitlyn Dobesh
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI.
| | | | - Loay S Kabbani
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Ali Rteil
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | - Alice Lee
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
| | | | - Mitchell Weaver
- Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI
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Jarosinski M, Kennedy JN, Khamzina Y, Alie-Cusson FS, Tzeng E, Eslami M, Sridharan ND, Reitz KM. Percutaneous thrombectomy for acute limb ischemia is associated with equivalent limb and mortality outcomes compared with open thrombectomy. J Vasc Surg 2024; 79:1151-1162.e3. [PMID: 38224861 PMCID: PMC11032234 DOI: 10.1016/j.jvs.2024.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/23/2023] [Accepted: 01/09/2024] [Indexed: 01/17/2024]
Abstract
BACKGROUND Acute limb ischemia (ALI) carries a 15% to 20% risk of combined death or amputation at 30 days and 50% to 60% at 1 year. Percutaneous mechanical thrombectomy (PT) is an emerging minimally invasive alternative to open thrombectomy (OT). However, ALI thrombectomy cases are omitted from most quality databases, limiting comparisons of limb and survival outcomes between PT and OT. Therefore, our aim was to compare in-hospital outcomes between PT and OT using the National Inpatient Sample. METHODS We analyzed survey-weighted National Inpatient Sample data (2015-2020) to include emergent admissions of aged adults (50+ years) with a primary diagnosis of lower extremity ALI undergoing index procedures within 2 days of hospitalization. We excluded hospitalizations with concurrent trauma or dissection diagnoses and index procedures using catheter-directed thrombolysis. Our primary outcome was composite in-hospital major amputation or death. Secondary outcomes included in-hospital major amputation, death, in-hospital reintervention (including angioplasty/stent, thrombolysis, PT, OT, or bypass), and extended length of stay (eLOS; defined as LOS >75th percentile). Adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs) were generated by multivariable logistic regression, adjusting for demographics, frailty (Risk Analysis Index), secondary diagnoses including atrial fibrillation and peripheral artery disease, hospital characteristics, and index procedure data including the anatomic thrombectomy level and fasciotomy. A priori subgroup analyses were performed using interaction terms. RESULTS We included 23,795 survey-weighted ALI hospitalizations (mean age: 72.2 years, 50.4% female, 79.2% White, and 22.3% frail), with 7335 (30.8%) undergoing PT. Hospitalization characteristics for PT vs OT differed by atrial fibrillation (28.7% vs 36.5%, P < .0001), frequency of intervention at the femoropopliteal level (86.2% vs 88.8%, P = .009), and fasciotomy (4.8% vs 6.9%, P = .006). In total, 2530 (10.6%) underwent major amputation or died. Unadjusted (10.1% vs 10.9%, P = .43) and adjusted (aOR = 0.96 [95% CI, 0.77-1.20], P = .74) risk did not differ between the groups. PT was associated with increased odds of reintervention (aOR = 2.10 [95% CI, 1.72-2.56], P < .0001) when compared with OT, but this was not seen in the tibial subgroup (aOR = 1.31 [95% CI, 0.86-2.01], P = .21, Pinteraction < .0001). Further, 79.1% of PT hospitalizations undergoing reintervention were salvaged with endovascular therapy. Lastly, PT was associated with significantly decreased odds of eLOS (aOR = 0.80 [95% CI, 0.69-0.94], P = .005). CONCLUSIONS PT was associated with comparable in-hospital limb salvage and mortality rates compared with OT. Despite an increased risk of reintervention, most PT reinterventions avoided open surgery, and PT was associated with a decreased risk of eLOS. Thus, PT may be an appropriate alternative to OT in appropriately selected patients.
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Affiliation(s)
| | - Jason N Kennedy
- Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh, Pittsburgh, PA; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Edith Tzeng
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Mohammad Eslami
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | - Katherine M Reitz
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
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Huttler JJ, Satam KK, Kim TI, Zhuo H, Zhang Y, Aboian E, Guzman RJ, Chaar CIO. Perioperative complications of minor and major reinterventions for peripheral arterial disease. Vascular 2024:17085381241246907. [PMID: 38597200 DOI: 10.1177/17085381241246907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
INTRODUCTION Patients with peripheral arterial disease (PAD) frequently require reinterventions after lower-extremity revascularization (LER) to maintain perfusion. Current Society for Vascular Surgery guidelines define reinterventions as major or minor based on the magnitude of the procedure. While prior studies have compared primary LER procedures of different magnitudes, similar studies for reinterventions have not been performed. The objective of this study is to compare perioperative outcomes associated with major and minor reinterventions. METHODS Patients undergoing LER for PAD at a tertiary care center from 2013 to 2017 were included. A retrospective review of electronic medical records was performed, and reinterventions were categorized as major or minor based on the procedure magnitude. Minor reinterventions included endovascular procedures and open revision with patch angioplasty, while major reinterventions were characterized by open surgical or endovascular LER with catheter-directed thrombolysis (CDT). Perioperative outcomes following LER were captured and compared for major and minor reinterventions. An additional subgroup analysis was performed comparing outcomes associated with major reinterventions stratified into open major surgical reinterventions and CDT. RESULTS This study included 713 patients over a mean follow-up of 2.5 years. A total of 291 patients underwent 696 ipsilateral reinterventions (range = 1-12 reinterventions). Most reinterventions were minor (72.1%, N = 502) and 27.9% (N = 194) were major. Patients receiving reinterventions had an average age of 67.2 ± 11.5 and most were white (73.5%) males (60.1%) initially treated for claudication (58.2%) and CLTI (41.8%). There was significantly higher post-operative bleeding (9.8% vs 3.4%, p = .001), arterial thrombosis (3.1% vs 1.0%, p = .047), and acute renal failure (6.2% vs 2.4%, p = .014) after major reinterventions than minor. Additionally, major reinterventions had significantly higher return to the OR (17.0% vs 11.3%, p = .046) and longer hospital stays (7.5 vs 4.3 days, p = <.0001). Overall, major reinterventions were associated with significantly increased perioperative morbidity (37.6% vs 19.7%, p ≤ .001) with no difference in perioperative mortality. In the subgroup analysis, open reinterventions resulted in significantly longer hospital stays (8.6 days vs 5.5 days, p ≤ .001) and more wound infections than CDT (11.0% vs 0%, p = .017). However, there was no other significant difference in morbidity or mortality following treatment with open surgical reinterventions or CDT. CONCLUSIONS In this study, major reinterventions after LER were associated with greater perioperative morbidity than minor reinterventions, with no difference in mortality. Major reinterventions performed via open surgery and CDT had similar morbidity and mortality.
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Affiliation(s)
- Joshua J Huttler
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Keyuree K Satam
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Tanner I Kim
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Haoran Zhuo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Yawei Zhang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Edouard Aboian
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Raul J Guzman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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Espitia O, Del Giudice C, Hartung O, Herquelot E, Schmidt A, Sapoval M, Sobocinski J. Editor's Choice -- Survival, Limb Salvage, and Management of Patients with Lower Limb Acute Ischaemia: A French National Retrospective Observational Study. Eur J Vasc Endovasc Surg 2024; 67:631-642. [PMID: 37926151 DOI: 10.1016/j.ejvs.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/22/2023] [Accepted: 11/01/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE The aim was to describe the baseline characteristics of French patients referred with acute limb ischaemia (ALI), and their clinical management and outcome (death, amputation). METHODS This retrospective observational cohort study used the National Health Data System. All adults hospitalised for ALI who underwent revascularisation with an endovascular or open surgical approach between 1 January 2015 and 31 December 2020 were included and followed up until death or the end of the study (31 December 2021). A one year look back period was used to capture patients' medical history. The risks of death, and major and minor amputations were described using Kaplan-Meier and Aalen-Johansen estimators. A Cox model was used to report the adjusted association between groups and risk of death and Fine-Gray models for the risk of amputations considering the competing risk of death. RESULTS Overall, 51 390 patients (median age 70 years, 69% male) were included and had a median follow up of 2.7 years: 39 411 (76.7%) were treated with an open approach and 11 979 (23.3%) with a percutaneous endovascular approach. The preferred approach for the revascularisation varied between French regions. The one year overall survival was 78.0% and 85.2% in the surgery and endovascular groups, respectively. The surgery group had a higher risk of death (hazard ratio [HR] 1.17, 95% CI 1.12 - 1.21), a higher risk of major amputation (sub-distribution HR 1.20, 95% CI 1.10 - 1.30) and lower risk of minor amputation (sub-distribution HR 0.66, 95% CI 0.60 - 0.71) than the endovascular group. Diabetes and dialysis increased the risk of major amputation by 52% and 78%, respectively. Subsequent ALI was the third most common cause of hospital re-admission within one year. CONCLUSION ALI remains a condition at high risk of death and amputation. Individual risk factors and ALI severity need to be considered to choose between approaches. Continued prevention efforts, improved management, and access to the most suitable approach are necessary.
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Affiliation(s)
- Olivier Espitia
- Nantes Université, CHU Nantes, Department of internal and vascular medicine, F-44000 Nantes, France.
| | | | - Olivier Hartung
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Nord, Marseille, France
| | | | | | - Marc Sapoval
- Radiologie interventionnelle, Hôpital Européen Georges-Pompidou, Paris, France
| | - Jonathan Sobocinski
- Chirurgie vasculaire et endovasculaire, Centre Hospitalier Universitaire de Lille, Lille, France
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Carboni J, Sadaghianloo N, Haudebourg P, Declemy S, Hassen-Khodja R, Jean-Baptiste E. Role of Anticoagulation in Nonagenarian Patients with Acute Limb Ischemia. Ann Vasc Surg 2024; 100:200-207. [PMID: 37918663 DOI: 10.1016/j.avsg.2023.09.075] [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: 06/30/2023] [Revised: 09/12/2023] [Accepted: 09/18/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Preoperative anticoagulant therapy is known to have a positive impact on the prognosis of patients with acute limb ischemia (ALI). However, little is known about its efficacy in elderly patients. We aimed to investigate the potential effect of anticoagulation in nonagenarian patients managed for ALI. METHODS Between January 2015 and December 2021, we identified all nonagenarian patients managed for ALI at a single center. Long-term anticoagulation and hemostasis parameters (prothrombin rate, activated partial thromboplastin time [APTT], platelet count) measured on admission were reviewed. The primary end point was mortality at 30-day mortality (D30) in patients with or without long-term anticoagulation therapy. We also studied the effect of these factors on the occurrence of revascularization failure in operated patients (initial failure, ischemic recurrence during hospitalization, necrosis requiring major amputation). RESULTS A total of 68 nonagenarian patients were managed for ALI, with a mean age of 93.8 years (from 90-107 years), 76.5% of whom were women. Of these patients, 47 (69%) were managed surgically. Long-term anticoagulation therapy was associated with better survival at D30, both in nonoperated (P < 0.01) and operated (P < 0.05) patients. In operated patients, the absence of long-term anticoagulation therapy was associated with the occurrence of revascularization failure (P < 0.05). In operated patients, survival to D30 and successful revascularization were associated with a longer APTT (P < 0,05). We were able to observe the survival of 4 patients contraindicated for surgery and treated with a single medical therapy (intravenous unfractionated heparin). CONCLUSIONS Anticoagulation appears to have an impact on the survival and postoperative prognosis of nonagenarian patients with ALI. In addition, curative anticoagulation therapy may be an alternative treatment when surgery is contraindicated in this frail population.
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Affiliation(s)
- Joseph Carboni
- INSERM U1065, CHU de Nice, Service de chirurgie vasculaire, Université Côte D'Azur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Nirvana Sadaghianloo
- INSERM U1065, CHU de Nice, Service de chirurgie vasculaire, Université Côte D'Azur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Pierre Haudebourg
- INSERM U1065, CHU de Nice, Service de chirurgie vasculaire, Université Côte D'Azur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Serge Declemy
- INSERM U1065, CHU de Nice, Service de chirurgie vasculaire, Université Côte D'Azur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Réda Hassen-Khodja
- INSERM U1065, CHU de Nice, Service de chirurgie vasculaire, Université Côte D'Azur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Elixène Jean-Baptiste
- INSERM U1065, CHU de Nice, Service de chirurgie vasculaire, Université Côte D'Azur, Centre Hospitalier Universitaire de Nice, Nice, France.
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10
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Soares RDA, Campos ABC, Portela MVV, Brienze CS, Brancher GQB, Sacilotto R. Pharmacomechanical thrombectomy with Angiojet in acute arterial occlusions: A prospective study among the results and outcomes. Vascular 2024:17085381241237559. [PMID: 38429875 DOI: 10.1177/17085381241237559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
OBJECTIVE The main objective of this present paper was to evaluate the results and outcomes of patients with acute limb ischemia (ALI) submitted to pharmacomechanical thrombectomy (PMT) endovascular surgery with Angiojet, regarding the number of cycles/pumps. METHODS Prospective, consecutive cohort study of ALI patients submitted to PMT endovascular intervention subdivided into two groups according to the number of cycles in the Angiojet technique: Group 1 higher than 150 cycles/second and Group 2 lesser than 150 cycles/second (cycles/s). RESULTS Overall, 92 patients with ALI submitted to PMT were evaluated. Two groups of patients were identified: Group 1 higher than 150 cycles/s with 60 patients and Group 2 lesser than 150 cycles/s with 32 patients. The overall mortality rate (OMR) was 15.1% (13 patients) in total cohort within the first 30 days. Group 1 had a higher OMR than Group 2 (16.1% vs 9.3%, p = 0.007). There were 4 cases of hematuria (4.3%), all of them in Group 1. We have performed a Kaplan-Meier regarding limb salvage rates: Group 1 had 85% and Group 2 had 95.7% at 1057 days. P = 0.081. Among the factors evaluated, the following were related to overall mortality rate: PMT with higher >150 cycles/s (HR = 7.17, p = 0.007, CI: 1.38-8.89), COVID-19 infection (HR = 2.75, p = 0.010, CI = 1.73-5.97), and post-operative acute kidney injury (HR = 2.97, p < 0.001, CI = 1.32-8.13). Among the factors evaluated, the following was related to limb loss: post-operative acute kidney injury (HR = 4.41, p = 0.036, CI: 1.771-7.132), probably because patients experiencing limb loss have a higher incidence of acute renal insufficiency due to higher circulating myoglobin higher hemolysis from the increased Angiojet cycles inducing rhabdomyolysis. CONCLUSION PMT with Angiojet is a safe and effective therapy in patients with ALI. However, patients receiving greater than 150 cycles/s were noted to have higher rates of acute kidney injury and mortality. This is likely reflective of increased thrombus burden and higher rates of hemolysis. Acute kidney injury, greater than 150 cycles/s, and COVID-19 infection were the variables with the strongest association to perioperative mortality.
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Affiliation(s)
- Rafael de Athayde Soares
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Ana Beatriz Campelo Campos
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Matheus Veras Viana Portela
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | - Carolina Sabadoto Brienze
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
| | | | - Roberto Sacilotto
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, Sao Paulo, Brazil
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Tan M, Takahara M, Haraguchi T, Uchida D, Dannoura Y, Shibata T, Iwata S, Azuma N. One-Year Clinical Outcomes and Prognostic Factors Following Revascularization in Patients With Acute Limb Ischemia - Results From the RESCUE ALI Study. Circ J 2024; 88:331-338. [PMID: 37544740 DOI: 10.1253/circj.cj-23-0348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
BACKGROUND Acute limb ischemia (ALI) is a limb- and life-threatening condition and urgent treatment including revascularization should be offered to patients unless the limb is irreversibly ischemic. The aim of this study was to investigate 1-year clinical outcomes and prognostic factors following revascularization in patients with ALI. METHODS AND RESULTS A retrospective, multicenter, nonrandomized study examined 185 consecutive patients with ALI treated by surgical revascularization (SR), endovascular revascularization (ER), or hybrid revascularization (HR) in 6 Japanese medical centers from January 2015 to August 2021. The 1-year amputation-free survival (AFS) rate was estimated to be 69.2% (95% confidence interval [CI], 62.8-76.2%). There were no significant differences among SR, ER, and HR regarding both technical success and perioperative complications. Multivariate analysis revealed that Rutherford category IIb and III ischemia (hazard ratio [HR]: 1.86; 95% CI: 1.06-3.25), supra- to infrapopliteal lesion (HR: 2.06; 95% CI: 1.08-3.95), and technical failure (HR: 2.58; 95% CI: 1.49-4.46) were independent risk factors for 1-year AFS. CONCLUSIONS Rutherford category IIb and III ischemia, supra- to infrapopliteal lesions, and technical failures were identified as independent risk factors for 1-year AFS. Furthermore, patients with multiple risk factors had a lower AFS rate.
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Affiliation(s)
- Michinao Tan
- Cardiovascular Center Tokeidai Memorial Hospital
| | - Mitsuyoshi Takahara
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine
| | | | - Daiki Uchida
- Department of Vascular Surgery, Asahikawa Medical University
| | - Yutaka Dannoura
- Department of Cardiovascular Medicine, Sapporo City General Hospital
| | - Tsuyoshi Shibata
- Department of Cardiovascular Surgery, Sapporo Medical University
| | - Shuko Iwata
- Cardiovascular Center Tokeidai Memorial Hospital
- Department of Cardiovascular Medicine, Nayoro City General Hospital
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
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12
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Arnold J, Koyfman A, Long B. High risk and low prevalence diseases: Acute limb ischemia. Am J Emerg Med 2023; 74:152-158. [PMID: 37844359 DOI: 10.1016/j.ajem.2023.09.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/26/2023] [Accepted: 09/29/2023] [Indexed: 10/18/2023] Open
Abstract
INTRODUCTION Acute limb ischemia is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of acute limb ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Acute limb ischemia is defined as a sudden decrease in limb perfusion resulting in cessation of blood flow and nutrient and oxygen delivery to the tissues. This leads to cellular injury and necrosis, ultimately resulting in limb loss and potentially systemic symptoms with significant morbidity and mortality. There are several etiologies including native arterial thrombosis, arterial thrombosis after an intervention, arterial embolus, and arterial injury. Patients with acute limb ischemia most commonly present with severe pain and sensory changes in the initial stages, with prolonged ischemia resulting in weakness, sensory loss, and color changes to the affected limb. The emergency clinician should consult the vascular specialist as soon as ischemia is suspected, as the diagnosis should be based on the history and examination. Computed tomography angiography is the first line imaging modality, as it provides valuable information concerning the vasculature and surrounding tissues. Doppler ultrasound of the distal pulses may also be obtained to evaluate for arterial and venous flow. Once identified, management includes intravenous unfractionated heparin and vascular specialist consultation for revascularization. CONCLUSIONS An understanding of acute limb ischemia can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Jacob Arnold
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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13
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Konstantinou N, Argyriou A, Dammer F, Bisdas T, Chlouverakis G, Torsello G, Tsilimparis N, Stavroulakis K. Outcomes After Open Surgical, Hybrid, and Endovascular Revascularization for Acute Limb Ischemia. J Endovasc Ther 2023:15266028231210232. [PMID: 38009372 DOI: 10.1177/15266028231210232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
PURPOSE To report the performance of surgical treatment (ST), hybrid treatment (HT), and endovascular treatment (ET) for patients with acute limb ischemia (ALI). METHODS This is a retrospective, comparative study of all consecutive patients with ALI treated in 2 tertiary centers between April 2010 and April 2020. Amputation and/or death (amputation-free survival; AFS) was the primary composite endpoint. Mortality, major amputation, and reintervention during follow-up were additionally analyzed. Proportional hazards modeling was used to identify confounders, results are presented as hazard ratio (HR) and 95% confidence intervals (CIs). RESULTS In total, 395 patients (mean age=71.1±13.6 years; 51.1% female) were treated during the study period. Surgical treatment was preferred in 150 patients (38%), while 98 were treated by HT (24.8%) and 147 by ET (37.2%). Rutherford class IIa was the most common clinical presentation in the ET group (50.3%), whereas Rutherford IIb was most common in the ST (54%) and HT (48%) groups (p<0.001). Significantly, more patients presented with a de novo lesion in the ST and HT groups (79.3% and 64.3%, respectively) compared with ET (53.7%; p<0.001). Median follow-up was 20 months (range=0-111 months). In the multivariate analysis, ET showed significantly better AFS during follow-up compared with ST (HR=1.89, 95% CI=1.2-2.9, p<0.001) and HT (HR=1.73, 95% CI=1.1-3.1, p<0.001). Mortality during follow-up was also significantly lower after ET compared with ST (HR=2.21, 95% CI=1.31-3.74, p=0.003) and HT (HR=2.04, 95% CI=1.17-3.56, p=0.012). Endovascular treatment was associated with lower amputation rate compared with ST (HR=2.27, 95% CI=1.19-4.35, p=0.013) but was comparable with HT (HR=2.00, 95% CI=0.98-4.06, p=0.055). Reintervention rates did not differ significantly between the groups (ET vs ST: HR=1.52, 95% CI=0.99-2.31, p=0.053; ET vs HT: HR=1.3, 95% CI=0.81-2.07, p=0.27). CONCLUSION Endovascular treatment for ALI was associated with improved AFS and comparable reintervention rates compared with open surgical and hybrid therapy. CLINICAL IMPACT Treatment of acute lower limb ischemia remains a challenge for clinicians with high morbidity and mortality rates. Endovascular revascularization is considered first line treatment for many and hybrid treatments are becoming more common, however data is limited to either old trials, small series or with short follow-up. We present herein our 10-year experience with all available devices and techniques for open surgical, endovascular and hybrid acute limb ischemia treatments and compare their outcomes.
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Affiliation(s)
| | - Angeliki Argyriou
- Department of Vascular Surgery, Marien Hospital Herne, Herne, Germany
| | - Felicitas Dammer
- Department of Vascular Surgery, University Hospital LMU Munich, Munich, Germany
| | - Theodosios Bisdas
- Department of Vascular and Endovascular Surgery, Athens Medical Center, Athens, Greece
| | - Gregory Chlouverakis
- Biostatistics Laboratory, Department of Social Medicine, School of Medicine, University of Crete, Crete, Greece
| | - Giovanni Torsello
- Department of Vascular Surgery, St. Franziskus Hospital GmbH, Muenster, Germany
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14
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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.
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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.)
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15
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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.
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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
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16
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Kukulski L, Pfister K, Schierling W, Sachsamanis G, Betz T. Impact of Revascularization Technique on the Outcomes of Peripheral Graft Revision Procedures. Ann Vasc Surg 2023:S0890-5096(23)00119-X. [PMID: 36863489 DOI: 10.1016/j.avsg.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/09/2023] [Accepted: 02/14/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND The acute occlusion of a peripheral bypass graft leads to acute limb ischemia (ALI) and threatens the viability of the limb if left untreated. The aim of the present study was to analyze the results of surgical and hybrid revascularization techniques for patients with ALI due to peripheral graft occlusions. METHODS A retrospective analysis of 102 patients undergoing treatment for ALI due to peripheral graft occlusion between 2002 and 2021 was carried out at a tertiary vascular center. Procedures were classified as surgical when only surgical techniques were used and as hybrid when surgical procedures were combined with endovascular techniques such as balloon or stent angioplasty or thrombolysis. Endpoints were primary and secondary patency and amputation-free survival after 1 and 3 years. RESULTS Of all patients, 67 met the inclusion criteria, 41 were treated surgically and 26 by hybrid procedures. There were no significant differences in the 30-day patency rate, 30-day amputation rate, and 30-day mortality. The 1- and 3-year primary patency rates were 41.4% and 29.2% overall, respectively; 45% and 32.1% in the surgical group, respectively; and 33.2% and 26.6% in the hybrid group, respectively. The 1- and 3-year secondary patency rates were 54.1% and 35.8% overall, respectively; 52.5% and 34.2% in the surgical group, respectively; and 54.4% and 43.5% in the hybrid group, respectively. The 1- and 3-year amputation-free survival rates were 67.5% and 59.2%, overall, respectively; 67.3% and 67.3% in the surgical group, respectively; and 68.5% and 48.2% in the hybrid group, respectively. There were no significant differences between the surgical and the hybrid groups. CONCLUSIONS The results of surgical and hybrid procedures after bypass thrombectomy for ALI to eliminate the cause of infrainguinal bypass occlusion are comparable with good midterm results in terms of amputation-free survival. New endovascular techniques and devices need to be established in comparison to the results of these proven surgical revascularization methods.
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Affiliation(s)
- Leszek Kukulski
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany; Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland.
| | - Karin Pfister
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Wilma Schierling
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Georgios Sachsamanis
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Betz
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
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Xu J, Yu Q, Zhu G, Zhao Z, Xiao Y, Bao J, Yuan L. Sex-related differences in the effect of rotational thrombectomy for thrombus-containing lower limbs ischemic lesions. Thromb J 2022; 20:78. [PMID: 36527031 PMCID: PMC9758767 DOI: 10.1186/s12959-022-00437-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/04/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND To assess the immediate effect and factors affecting the efficacy of rotational thrombectomy (RT) in patients with thrombus-containing lower-limb ischaemic lesions. METHODS Patients were retrospectively divided into two groups: RT and RT+ CDT (Catheter-directed thrombolysis). The RT group included patients in whom intraoperative thrombus aspiration was successful, while the RT + CDT group included patients in whom intraoperative thrombus aspiration was less effective and remedial CDT treatment was used. The primary outcome was the immediate effect of RT on thrombus-containing lower-limb ischaemic lesions. RESULTS From May 2015 to July 2021, 170 patients (113 men, 57 women; mean age, 74.0 years) with thrombus-containing lower-limb ischaemic lesions were treated in our centre. Of these patients, 113 received RT only, while 57 received RT + CDT. There were no significant intergroup differences in terms of age, disease duration, or comorbidities, but a higher proportion of male patients and higher preoperative plasma D-dimer levels (1.23 vs. 0.84; p = .017) was observed in the RT + CDT group. There were no significant intergroup differences in terms of diagnosis, lesion characteristics, lesion location, or lesion length. Multivariate logistic regression analysis revealed that male sex (odds ratio [OR], 2.65; 95% confidence interval [CI], 1.098-6.410; p = .030) and poor distal runoff (OR, 2.94; 95% CI, 1.439-5.988; p = .003) were associated with higher rates of additional CDT. Male patients also had a significantly longer onset time, more thrombotic occlusions, and a greater frequency of in-stent restenosis. CONCLUSIONS RT alone or with CDT is a feasible primary treatment option for thrombus debulking. Sex significantly influences the effect of RT on thrombus-containing lower-limb ischaemic lesions.
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Affiliation(s)
- Jinyan Xu
- grid.411525.60000 0004 0369 1599Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, 168 Changhai Road, Shanghai, 200433 People’s Republic of China
| | - Qingyuan Yu
- grid.411525.60000 0004 0369 1599Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, 168 Changhai Road, Shanghai, 200433 People’s Republic of China
| | - Guanglang Zhu
- grid.8547.e0000 0001 0125 2443Department of Vascular Surgery, Qingpu Branch of Zhongshan Hospital, Affiliated to Fudan University, Shanghai, 201700 China
| | - Zhiqing Zhao
- grid.411525.60000 0004 0369 1599Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, 168 Changhai Road, Shanghai, 200433 People’s Republic of China
| | - Yu Xiao
- grid.411525.60000 0004 0369 1599Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, 168 Changhai Road, Shanghai, 200433 People’s Republic of China
| | - Junmin Bao
- grid.411525.60000 0004 0369 1599Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, 168 Changhai Road, Shanghai, 200433 People’s Republic of China
| | - Liangxi Yuan
- grid.411525.60000 0004 0369 1599Department of Vascular Surgery, Changhai Hospital, Navy Military Medical University, 168 Changhai Road, Shanghai, 200433 People’s Republic of China
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18
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Andraska EA, Phillips AR, Reitz KM, Asaadi S, Ho J, McDonald MM, Madigan M, Liang N, Eslami M, Sridharan N. Young patients without prior vascular disease are at increased risk of limb loss and reintervention after acute limb ischemia. J Vasc Surg 2022; 76:1354-1363.e1. [PMID: 35709858 PMCID: PMC9890507 DOI: 10.1016/j.jvs.2022.04.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/16/2022] [Accepted: 04/24/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND The objective of the present study was to categorize the presentation and treatment of acute limb ischemia (ALI) in young patients and compare the adverse outcomes after revascularization compared with that of older patients. METHODS All the patients who had presented to a multi-institution healthcare system with ALI from 2016 to 2020 were identified. The presenting features, operative details, and outcomes were included in the present analysis. Patients with existing peripheral arterial disease (acute on chronic) were analyzed separately from those without (de novo thrombosis or embolus). Within these groups, younger patients (age, ≤50 years) were compared with older patients (age, >50 years). The 3-month major adverse limb event-free survival was the primary outcome. RESULTS A total of 232 patients (age, 60 ± 16 years; 44% female sex, 87% white race) were included in the analysis. Of the 232 patients, 119 were in the acute on chronic cohort and 113 were in the de novo thrombosis/embolism cohort. Age did not affect the overall outcomes (P = .45) or the outcomes for the acute on chronic group (P = .17). However, in the de novo thrombosis/embolism cohort, patients aged ≤50 years had worse major adverse limb event-free survival compared with patients aged >50 years (hazard ratio, 2.47; 95% confidence interval, 1.08-5.68; P = .03) after adjustment for Rutherford class, interval from presentation to the operating room, and smoking status. In the de novo thrombosis/embolism group, the operative approach was similar across the age groups (endovascular, 12% vs 14%; open, 48% vs 41%; hybrid, 41% vs 45%; P = .78). In the younger patients, embolism was more likely from a proximal arterial source (71%). In contrast, in the older patients, the source of embolism was more often a cardiac source (86%). The rates of hypercoagulable disease were equal across the age groups (10% vs 10%; P = .95). The In-hospital mortality was 3% overall (acute on chronic, 5%; de novo, 3%). CONCLUSIONS Despite advances in interventional options, for patients with ALI due to de novo thrombosis or embolus, younger age was associated with worse short-term limb-related outcomes.
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Affiliation(s)
- Elizabeth A Andraska
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Amanda R Phillips
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Katherine M Reitz
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Sina Asaadi
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jonathan Ho
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Michael Madigan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Nathan Liang
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mohammad Eslami
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Natalie Sridharan
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; University of Pittsburgh School of Medicine, Pittsburgh, PA
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Abstract
Acute limb ischemia (ALI) is a vascular emergency associated with high rates of limb loss and mortality. Management of these patients is challenging given the severe systemic illness resulting from tissue ischemia and the high incidence of preexisting comorbid conditions and underlying peripheral arterial disease. Expeditious diagnosis, anticoagulation, and revascularization are of utmost importance in reducing morbidity. Revascularization may be accomplished using open, endovascular, or hybrid techniques. Approach to revascularization depends on the severity of ischemia, location of occlusion, cause, chance of recovery, comorbidities, and available resources.
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Affiliation(s)
- Elizabeth G King
- Division of Vascular & Endovascular Surgery, Boston University School of Medicine 85 East Concord Street, Suite 3000, Boston, MA 02118, USA
| | - Alik Farber
- Division of Vascular & Endovascular Surgery, Boston University School of Medicine 85 East Concord Street, Suite 3000, Boston, MA 02118, USA.
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20
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Gupta R, Siada SS, Bronsert M, Al-Musawi MH, Nehler MR, Yi JA. High Rates of Recurrent Revascularization in Acute Limb Ischemia - a National Surgical Quality Improvement Program Study. Ann Vasc Surg 2022; 87:334-342. [PMID: 35817385 DOI: 10.1016/j.avsg.2022.06.019] [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: 04/26/2022] [Revised: 06/17/2022] [Accepted: 06/24/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to review outcomes of acute limb ischemia (ALI) patients following open surgical intervention for ALI. METHODS A previously validated tool was used to identify ALI patients in NSQIP undergoing open surgical revascularization from 2012-2017. Multivariable analysis was performed for the primary outcome of reoperation and secondary outcome of readmission and infection. RESULTS 2,878 ALI patients underwent open revascularization; 35.7% were transfers from another acute care hospital. 13.8% required reoperation and 7.9% required readmission within 30 days. 32% of reoperations were recurrent revascularization, representing 4.4% of all ALI patients. 58.7% of patients were female and either overweight or obese. Younger age (OR 0.991 [0.984-0.999], p=0.02), underweight patients (OR 1.159 [0.667-2.01], p=0.05), pre-operative steroid use (OR 1.61 [1.07-2.41], p=0.02), and perioperative transfusion (OR 2.02 [1.04-3.95], p=0.04) predicted reoperations. CONCLUSIONS This registry series demonstrates all-cause ALI patients are a different population than PAD with different risk factors. Despite being a time-critical condition, ALI has higher interhospital transfer rates than ACS or ruptured aneurysm. Following open revascularization, ALI outcomes are worse than ACS but better than ruptured AAA. These outcomes do not appear related to patient factors in contrast to revascularization for chronic PAD.
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Affiliation(s)
- Ryan Gupta
- Department of Surgery, University of Colorado Anschutz School of Medicine, Aurora, CO
| | - Sammy S Siada
- Division of Vascular Surgery, University of California San Francisco Fresno Hospital, Fresno, CA
| | | | | | - Mark R Nehler
- Division of Vascular Surgery, University of Colorado Anschutz School of Medicine, Aurora, CO
| | - Jeniann A Yi
- Division of Vascular Surgery, University of Colorado Anschutz School of Medicine, Aurora, CO.
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21
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BORIONI R, TOMAI F, MANCINELLI A, FIORELLI A, GUARNERA A, TESORI C, PACIOTTI C, GAROFALO M. Anatomical localization of arterial thrombosis in patients with acute lower limb ischemia secondary to atrial fibrillation: implications for surgical treatment and outcome. ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2022. [DOI: 10.23736/s1824-4777.22.01535-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Wang CC, Lu CR, Hsieh LC, Kuo CC, Huang PW, Chang KC, Chang CT, Hsu CH. Comparison of pharmaco-mechanical thrombolysis and catheter-directed thrombolysis for treating thrombotic or embolic arterial occlusion of the lower limb. INT ANGIOL 2022; 41:292-302. [PMID: 35437980 DOI: 10.23736/s0392-9590.22.04809-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Whether pharmaco-mechanical thrombolysis (PMT) results in superior outcomes to catheter-directed thrombolysis (CDT) in treating thrombotic or embolic arterial occlusion of the lower limbs is unclear. METHODS We enrolled 94 patients with Rutherford class I-IIb due to thrombotic or embolic arterial occlusion in the lower limbs and who received emergency endovascular treatment. Baseline demographics, laboratory data, angiography and clinical outcomes were collected through chart reviews and fluoroscopic imaging. The procedural characteristics (thrombolytic drug dosage, treatment duration, and additional procedures), immediate angiographic outcomes (patency of calf vessels, and complete lysis), complications (major bleeding, and fasciotomy), and primary composite end-points (30-day mortality, amputation, and reocclusion) were compared between patients who received CDT versus PMT. RESULTS Compared with CDT, PMT was independently associated with lower total UK dosage (standardised coefficientβ= - 0.44; p < 0.01) and higher prevalence of complete lysis (odds ratio = 1.78, 95% confidence interval: 1.03 - 3.06; p = 0.04) after adjustments of covariates. The PMT group had significantly shorter treatment duration (23.00 [7.25 - 39.13] vs. 41.00 [27.00 - 52.50]; p < 0.01). No significant intergroup differences were observed for the primary composite end point (10.7% vs. 9.1%; p = 0.81), or prevalence of the major bleeding (9.1% vs. 0.0%; p = 0.10) despite the PMT group comprising patients with more.advanced chronic kidney disease and more diffuse thrombosis. CONCLUSIONS PMT with a Rotarex is a safe and effective strategy for treating thrombotic or embolic lower limb ischemia. It significantly reduced the thrombolytic drug dosage, and resulted in the complete lysis being more likely.
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Affiliation(s)
- Chun-Cheng Wang
- School of Medicine, China Medical University, Thaicung, Taiwan.,Division of Cardiovascular Medicine, Department of Internal Medicine, China Medical University Hospital, Thaicung, Taiwan
| | - Chiung-Ray Lu
- Division of Cardiovascular Medicine, Department of Internal Medicine, China Medical University Hospital, Thaicung, Taiwan
| | - Li-Chuan Hsieh
- Division of Cardiovascular Medicine, Department of Internal Medicine, China Medical University Hospital, Thaicung, Taiwan
| | - Chin-Chi Kuo
- School of Medicine, China Medical University, Thaicung, Taiwan.,Big Data Center, China Medical University Hospital, Thaicung, Taiwan.,Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Thaicung, Taiwan.,Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Pei-Wen Huang
- Big Data Center, China Medical University Hospital, Thaicung, Taiwan.,Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Kuan-Cheng Chang
- School of Medicine, China Medical University, Thaicung, Taiwan.,Division of Cardiovascular Medicine, Department of Internal Medicine, China Medical University Hospital, Thaicung, Taiwan
| | - Chiz-Tzung Chang
- School of Medicine, China Medical University, Thaicung, Taiwan.,Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Thaicung, Taiwan
| | - Chung-Ho Hsu
- Division of Cardiovascular Medicine, Department of Internal Medicine, China Medical University Hospital, Thaicung, Taiwan -
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23
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de Athayde Soares R, Futigami AY, Barbosa AG, Sacilotto R. Acute arterial occlusions in covid-19 times: a comparison study among patients with acute limb ischemia with or without Covid-19 infection. Ann Vasc Surg 2022; 83:80-86. [PMID: 35452788 PMCID: PMC9020509 DOI: 10.1016/j.avsg.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/11/2022] [Accepted: 04/11/2022] [Indexed: 11/19/2022]
Abstract
Background To determine the impact of coronavirus (COVID-19) infection in patients with acute limb ischemia (ALI), mainly the limb salvage estimates the rate and the overall survival rate. Methods This was a prospective, consecutive cohort study of ALI patients with or without COVID-19 infection. Two groups of patients were identified: patients with ALI and COVID-19 infection and patients with ALI and without COVID-19 infection. The comparisons among the 2 groups were performed with proper statistical analysis methods. Results Two groups of patients were identified: ALI and COVID-19 infection with 23 patients and ALI without COVID-19 infection with 49 patients. The overall mortality rate (OMR) was 20.8% (15 patients) in total cohort within the first 30 days. COVID-19 group had a higher OMR than non–COVID-19 group (30.4% vs. 16.7%, P = 0.04). The limb salvage rate at 30 days was 79.1% in total cohort; however, non–COVID-19 infection group had higher limb salvage rates than COVID-19 infection group (89.7% vs. 60.8%, P = 0.01). A univariate and multivariate logistic regression was performed to test the factors related to a major amputation rate. Among the factors evaluated, the following were related to limb loss: D-dimer > 1,000 mg/mL (hazards ratio [HR] = 3.76, P = 0.027, CI = 1.85–5.89) and COVID-19 infection (HR = 1.38, P = 0.035, CI = 1.03–4.75). Moreover, a univariate and multivariate logistic regression analysis was performed to analyze the factors related to overall mortality. Among the factors evaluated, the following were related to OMR: D-dimer > 1,000 mg/dL (HR = 2.28, P = 0.038, CI: 1.94–6.52), COVID-19 infection (HR = 1.8, P = 0.018, CI = 1.01–4.01), and pharmacomechanical thrombectomy >150 cycles (HR = 2.01, P = 0.002, CI = 1.005–6.781). Conclusions COVID-19 has a worse prognosis among patients with ALI, with higher rates of limb loss and overall mortality relative to non-COVID patients. The main factors related to overall mortality were D-dimer > 1,000 mg/dL, COVID-19 infection, and pharmacomechanical thrombectomy >150 cycles. The factors related to limb loss were D-dimer > 1,000 mg/mL and COVID-19 infection.
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Affiliation(s)
- Rafael de Athayde Soares
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil.
| | - Aline Yoshimi Futigami
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Anndya Gonçalves Barbosa
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - Roberto Sacilotto
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo, São Paulo, Brazil
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24
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Sekar N, Jagan J, Viruthagiri A, Mandjiny N, Sivagnanam K. Management of Acute Limb Ischaemia Due to COVID-19 Induced Arterial Thrombosis: A Multi-Centre Indian Experience. Ann Vasc Dis 2022; 15:113-120. [PMID: 35860829 PMCID: PMC9257383 DOI: 10.3400/avd.oa.22-00012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/31/2022] [Indexed: 12/28/2022] Open
Abstract
Objective: To determine the outcomes following various surgical and medical treatments of Coronavirus disease 2019 (COVID-19) induced acute limb ischaemia. Methods: A retrospective study of patients presenting with COVID induced arterial ischaemia in three hospitals from Southern India during the months of May 2020 to August 2021 was undertaken. These patients were managed by either thrombectomy, primary bypass, thrombolysis, anticoagulation or primary amputation based on the stage of ischaemia and the severity of COVID. Results: A total of 67 limbs in 59 patients were analysed. The average time to intervention was 15 days. Upper limb involvement was seen in 16 and lower limb in 51 limbs. Of the 67 limbs, 39 (58.2%) were treated by open surgical revascularisation, 5 (7.4%) by catheter directed lysis, 17 (25.3%) were managed conservatively and 6 (8.9%) underwent primary amputation. Successful revascularisation could be carried out in 88.6% of patients. A limb salvage rate of 80.6% was achieved in these patients with a re-intervention rate of 13.6%. Major amputation rate was 14.92% and mortality was 13.56%. Conclusion: Limb ischaemia after COVID can be safely managed by open thrombectomy or bypass. Similar rates of limb salvage as in non-COVID acute limb ischaemia can be obtained.
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25
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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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/23/2020] [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.
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Affiliation(s)
| | - Mitsuyoshi Takahara
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshimitsu Soga
- Department of Cardiology, Kokura Memorial Hospital, Fukuoka, Japan
| | - Masahiko Fujihara
- Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Toshiaki Mano
- Cardiovascular Center, Kansai Rosai Hospital, Hyogo, Japan
| | - Masanobu Ohya
- Department of Cardiology, Kurashiki Central Hospital, Okayama, Japan
| | - Toshiro Shinke
- Department of Cardiology, Showa University School of Medicine, Tokyo, Japan
| | - Tetsuya Amano
- Department of Cardiology, Aichi medical University, Aichi, Japan
| | - Yuji Ikari
- Division of Cardiovascular Medicine, Tokai University Hospital, Kanagawa, Japan
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Minici R, Ammendola M, Talarico M, Luposella M, Minici M, Ciranni S, Guzzardi G, Laganà D. Endovascular recanalization of chronic total occlusions of the native superficial femoral artery after failed femoropopliteal bypass in patients with critical limb ischemia. CVIR Endovasc 2021; 4:68. [PMID: 34491477 PMCID: PMC8423883 DOI: 10.1186/s42155-021-00256-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/23/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Femoropopliteal bypass occlusions are a significant issue in patients with critical limb ischemia and chronic total occlusion of the native superficial femoral artery, which challenges vascular surgeons and interventional radiologists. Performing a secondary femoropopliteal bypass is still considered the standard of care, although it is associated with a higher complication rate and lower patency rate in comparison with primary bypass. Over the past few years, angioplasty has been commonly used, with the development in endovascular technologies, to treat chronic total occlusions of the native superficial femoral artery, with a good technical success rate and clinical prognosis. The purpose of the study is to assess the outcome of endovascular recanalization of chronic total occlusions of the native superficial femoral artery, in patients unfit for surgery with critical limb ischemia after failed femoropopliteal bypass. RESULTS A total of 54 patients were treated. 77.8 % of the conduits were PTFE grafts; the remainder were single-segment great saphenous veins. The most common clinical presentation was rest pain. Technical success was achieved in 51 (94.4 %) of 54 limbs. Angiographically, 77.8 % of the lesions were TASC II category D, while 22.2 % were TASC II category C. The average length of the native SFA lesions was 26.8 cm. Clinical success, with improved Rutherford classification staging, followed each case of technical success. The median follow-up value was 5.75 years (IQR, 1.5-7). By Kaplan-Meier survival analysis, primary patency rates were 61 % (± 0.07 SE) at 1 year and 46 % (± 0.07 SE) at 5 years. Secondary patency rates were 93 % (± 0.04 SE) at 1 year and 61 % (± 0.07 SE) at 5 years. Limb salvage rates were 94 % (± 0.03 SE) at 1 year and 88 % (± 0.05 SE) at 5 years. CONCLUSIONS The endovascular recanalization of chronic total occlusions (CTO) of the native superficial femoral artery (SFA) after a failed femoropopliteal bypass is a safe and effective therapeutic option in patients unfit for surgery with critical limb ischemia.
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Affiliation(s)
- Roberto Minici
- Radiology Division, Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, University Hospital Mater Domini, Viale Europa, 88100, Catanzaro, Italy.
| | - Michele Ammendola
- Digestive Surgery Unit, Science of Health Department, Magna Graecia University, Catanzaro, Italy
| | - Marisa Talarico
- Cardiology Division, Giovanni Paolo II Hospital, Lamezia Terme, Italy
| | - Maria Luposella
- Cardiovascular Disease Unit, San Giovanni di Dio Hospital, Crotone, Italy
| | - Marco Minici
- Institute for high performance computing and networking (ICAR), National Research Council (Cnr), Rende, Italy
| | - Salvatore Ciranni
- Vascular Surgery Division, University Hospital Mater Domini, Catanzaro, Italy
| | - Giuseppe Guzzardi
- Radiology Division, Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
| | - Domenico Laganà
- Radiology Division, Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, University Hospital Mater Domini, Viale Europa, 88100, Catanzaro, Italy
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27
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Yang PK, Su CC, Hsu CH. Clinical outcomes of surgical embolectomy versus catheter-directed thrombolysis for acute limb ischemia: a nationwide cohort study. J Thromb Thrombolysis 2021; 53:517-522. [PMID: 34342786 PMCID: PMC8904339 DOI: 10.1007/s11239-021-02532-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/17/2021] [Indexed: 11/30/2022]
Abstract
In Taiwan, the outcomes of acute limb ischemia have yet to be investigated in a standardized manner. In this study, we compared the safety, feasibility and outcomes of acute limb ischemia after surgical embolectomy or catheter-directed therapy in Taiwan. This study used data collected from the Taiwan's National Health Insurance Database (NHID) and Cause of Death Data between the years 2000 and 2015. The rate ratio of all-cause in-hospital mortality and risk of amputation during the same period of hospital stay were estimated using Generalized linear models (GLM). There was no significant difference in mortality risk between CDT and surgical intervention (9.5% vs. 10.68%, adjusted rate ratio (95% CI): regression 1.0 [0.79-1.27], PS matching 0.92 [0.69-1.23]). The risk of amputation was also comparable between the two groups. (13.59% vs. 14.81%, adjusted rate ratio (95% CI): regression 0.84 [0.68-1.02], PS matching 0.92 [0.72-1.17]). Age (p < 0.001) and liver disease (p = 0.01) were associated with higher mortality risks. Heart failure (p = 0.03) and chronic or end-stage renal disease (p = 0.03) were associated with higher amputation risks. Prior antithrombotic agent use (p = 0.03) was associated with a reduced risk of amputation. Both surgical intervention and CDT are effective and feasible procedures for patients with ALI in Taiwan.
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Affiliation(s)
- Po-Kai Yang
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, Dou-Liou Branch, College of Medicine, National Cheng Kung University, Yunlin, Taiwan
| | - Chien-Chou Su
- Department of Pharmacy, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Hsin Hsu
- Division of Critical Care, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng Li Road, Tainan, Taiwan.
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Schierling W, Bachleitner K, Kasprzak P, Betz T, Stehr A, Pfister K. Safety aspect of intraoperative, local urokinase lysis in patients with acute lower limb ischemia. Clin Hemorheol Microcirc 2021; 78:83-92. [PMID: 33523045 DOI: 10.3233/ch-201049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Acute lower limb ischemia (ALI) is associated with a high risk of limb loss and death. OBJECTIVE The present study evaluates the safety of intraoperative, local urokinase lysis in patients with ALI and crural artery occlusion. METHODS A total of 107 patients (115 legs) were treated surgically for ALI with additional intraoperative urokinase lysis to improve the outflow tract. Minor and major bleeding as well as efficacy of treatment and amputation-free survival were investigated. RESULTS Complete restoration of at least one run-off vessel was achieved in 64%. Collateralization was improved in 34%. Lysis failed in 2%. Major amputation rate was 27% overall (12% within 30 days) and depended on Rutherford class of ALI (overall/30 day: IIa 11%/6%; IIb 20%/17%; III 37%/15%). Amputation-free survival turned out to be 82% after 30 days, 58% after one, and 41% after five years. Minor bleeding occurred in 21% (24/115) and major bleeding in 3.5% (4/115). One of these patients died of haemorrhage. No patient experienced intracranial bleeding. CONCLUSION Intraoperative urokinase lysis improves limb perfusion and causes low major and intracranial bleeding. It can be safely applied to patients with severe ischaemia when surgical restoration of the outflow tract fails.
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Affiliation(s)
- Wilma Schierling
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Kathrin Bachleitner
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany.,Department of Hand, Breast, and Reconstructive Microsurgery, Marienhospital Stuttgart, Stuttgart, Germany
| | - Piotr Kasprzak
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Betz
- Department of Vascular Surgery, Barmherzige Brüder Hospital Regensburg, Regensburg, Germany
| | - Alexander Stehr
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany.,Department of Vascular Surgery, Evangelisches Krankenhaus Mülheim, Mülheim an der Ruhr, Germany
| | - Karin Pfister
- Department of Vascular Surgery, University Hospital Regensburg, Regensburg, Germany
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Rossi M, Tipaldi MA, Tagliaferro FB, Pisano A, Ronconi E, Lucertini E, Daffina J, Caruso D, Laghi A, Laurino F. Aspiration Thrombectomy with the Indigo System for Acute Lower Limb Ischemia: Preliminary experience and analysis of parameters affecting the outcome. Ann Vasc Surg 2021; 76:426-435. [PMID: 33951530 DOI: 10.1016/j.avsg.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 03/28/2021] [Accepted: 04/03/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose of our study is to assess the short-term technical success and the safety of the Indigo System in a series of patients undergoing vacuum-assisted catheter direct thrombus aspiration (IS-CDTA) for acute lower limb ischemia (ALLI) and to evaluate which parameters may affect the outcome. METHODS All procedures using the IS-CDTA for ALLI, performed in a single-centre Interventional Radiology Unit from February 2016 to March 2020, were retrospectively analysed. Technical success was defined as the achievement of nearly-complete or complete revascularization (TIPI grade 2/3) and considered as a good outcome. Variables potentially correlated with the IS-CDTA outcome were analysed. RESULTS 33 procedures were performed in 29 patients. Mean age was 69 years old (range 47 - 88), 24 males (83%) and 5 females (18%). The technical success was 70%. Catheter-directed thrombolysis following IS-CDTA was performed in 23 cases and the overall technical success increased from 70% to 90%, afterwards. The median time between symptoms insurgency and IS-CDTA was significantly shorter in patients with good outcome (10 hours; IQR 2.75-48) compared to those with poor outcome (168 hours; IQR 36-336) (P = 0.003). No statistically significant differences were found between the two groups regarding ATK vs. BTK (P = 0.34), native vessel vs. graft (P = 0.25), occlusion nature P = 0.28) or Rutherford score (P = 0.80). CONCLUSION IS-CDTA is a valid option for a rapid and percutaneous treatment of ALLI. Our experience indicates that the time elapsing from the symptoms insurgency and the endovascular procedure is the best positive predictor of the outcome.
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Affiliation(s)
- Michele Rossi
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza - University of Rome, Rome, Italy
| | - Marcello Andrea Tipaldi
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza - University of Rome, Rome, Italy.
| | - Francesco Bruno Tagliaferro
- Department of Radiology and Interventional Radiology, Sant'Andrea University Hospital La Sapienza, Rome, Italy
| | - Andrea Pisano
- Department of Radiology and Interventional Radiology, Sant'Andrea University Hospital La Sapienza, Rome, Italy
| | - Edoardo Ronconi
- Department of Radiology and Interventional Radiology, Sant'Andrea University Hospital La Sapienza, Rome, Italy
| | - Elena Lucertini
- Department of Radiology and Interventional Radiology, Sant'Andrea University Hospital La Sapienza, Rome, Italy
| | - Julia Daffina
- Department of Radiology and Interventional Radiology, Sant'Andrea University Hospital La Sapienza, Rome, Italy
| | - Damiano Caruso
- Department of Radiological Sciences, Oncological and Pathological Sciences, Sapienza- Sant'Andrea University Hospital, University of Rome, Rome, Italy
| | - Andrea Laghi
- Department of Surgical and Medical Sciences and Translational Medicine, Sapienza - University of Rome, Rome, Italy
| | - Florindo Laurino
- Department of Radiology and Interventional Radiology, Sant'Andrea University Hospital La Sapienza, Rome, Italy
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Ueda T, Tajima H, Murata S, Saito H, Yasui D, Sugihara F, Mine T, Miki I, Kurita J, Morota T, Ishii Y, Yokobori S, Kumita SI. A Comparison of Outcomes Based on Vessel Type (Native Artery vs. Bypass Graft) and Artery Location (Below-Knee Artery vs. Non-Below-Knee Artery) Using a Combination of Multiple Endovascular Techniques for Acute Lower Limb Ischemia. Ann Vasc Surg 2021; 75:205-216. [PMID: 33819584 DOI: 10.1016/j.avsg.2021.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/08/2021] [Accepted: 02/12/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND To evaluate outcomes of endovascular treatment (EVT) using a combination of multiple endovascular techniques for acute lower limb ischemia (ALLI) and to compare outcomes based on vessel type and artery location. METHODS A total of 95 consecutive patients with ALLI (mean age, 72.0 years; 65 males; 104 lower limbs) who received emergency EVT using a combination of multiple endovascular techniques including thrombolysis, aspiration thrombectomy, stenting, and balloon angioplasty with or without surgical thromboembolectomy, between January 2005 and December 2017 were included. Vessel type was classified into native artery occlusion (native occlusion) and bypass graft occlusion (graft occlusion), including prosthetic and vein graft. Additionally, native arteries were categorized into below-knee occlusion and non-below-knee occlusion. Technical success, perioperative death (POD), ALLI-related death, amputation, amputation-free survival (AFS), and complications were compared according to vessel type (native occlusion vs. graft occlusion) and artery location (below-knee occlusion vs. non-below-knee occlusion). RESULTS Of all patients with ALLI, 16.8% underwent a single endovascular technique, whereas 83.2% underwent a combination of multiple endovascular techniques. The technicalsuccess, POD, and ALLI-related death rates in the total number of patients were 94.7%, 11.6%, and 4.2%, respectively. A total of 67 patients (75 limbs) and 28 patients (29 limbs) were classified as having native occlusion and graft occlusion (prosthetic, 24 limbs; vein, 5 limbs), respectively. No significant differences in technical success (native occlusion: 92.5% vs. graft occlusion: 100%), POD (14.9% vs. 3.6%), and ALLI-related death (6.0% vs. 0%) were noted between native occlusion and graft occlusion. However, the 30-day AFS rate of native occlusion was significantly lower than that of graft occlusion (75.2% vs. 96.3%, P=0.01). The amputation rate (P=0.03) and AFS rate (P=0.03) of below-knee occlusion were significantly worse for below-knee occlusion patients than for non-below-knee occlusion patients. CONCLUSIONS EVT using multiple endovascular techniques for ALLI is effective and safe. A combination of multiple endovascular techniques is crucial for successful treatment. However, native occlusion may have a lower AFS rate than graft occlusion, and below-knee occlusion may have a higher risk of amputation than non-below-knee occlusion.
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Affiliation(s)
- Tatsuo Ueda
- Department of Radiology, Nippon Medical School Hospital, Bunkyo, Tokyo, Japan.
| | - Hiroyuki Tajima
- Department of Diagnostic Imaging, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Satoru Murata
- Center for Interventional Radiology, Teikyo University Chiba Medical Center, Ichihara, Chiba, Japan
| | - Hidemasa Saito
- Department of Radiology, Nippon Medical School Hospital, Bunkyo, Tokyo, Japan
| | - Daisuke Yasui
- Department of Radiology, Nippon Medical School Hospital, Bunkyo, Tokyo, Japan
| | - Fumie Sugihara
- Department of Radiology, Nippon Medical School Hospital, Bunkyo, Tokyo, Japan
| | - Takahiko Mine
- Department of Radiology, Nippon Medical School Chiba Hokusoh Hospital, Inzai, Chiba, Japan
| | - Izumi Miki
- Department of Radiology, Nippon Medical School Hospital, Bunkyo, Tokyo, Japan
| | - Jiro Kurita
- Department of Cardiovascular Surgery, Nippon Medical School, Bunkyo, Tokyo, Japan
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School, Bunkyo, Tokyo, Japan
| | - Yosuke Ishii
- Department of Cardiovascular Surgery, Nippon Medical School, Bunkyo, Tokyo, Japan
| | - Shoji Yokobori
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Bunkyo, Tokyo, Japan
| | - Shin-Ichiro Kumita
- Department of Radiology, Nippon Medical School Hospital, Bunkyo, Tokyo, Japan
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Poursina O, Elizondo-Adamchik H, Montero-Baker M, Pallister ZS, Mills JL, Chung J. Safety and efficacy of an endovascular-first approach to acute limb ischemia. J Vasc Surg 2020; 73:1741-1749. [PMID: 33068768 DOI: 10.1016/j.jvs.2020.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 10/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The optimal techniques to manage acute limb ischemia (ALI) remain unclear. Previous reports have suggested that the decreased morbidity and mortality of endovascular approaches are mitigated by the limited technical success rates relative to open or hybrid approaches for ALI. However, these data failed to include newer technologies that might improve the technical success rates. We, therefore, sought to describe the current outcomes for an endovascular-first approach to ALI. METHODS We performed a single-center, single-arm, retrospective cohort study of consecutive patients with ALI from 2015 to 2018. Technical success, limb salvage, survival, patency, and length of stay were quantified using Kaplan-Meier (KM) analysis. Cox regression analysis was used to identify the predictors of amputation-free survival. RESULTS During the 3 years, 60 consecutive patients (39 men [65%]; median age, 65 years) presented with ALI. The Rutherford class was I in 15 patients (25%), IIa in 23 (38%), IIb in 13 (22%), and III in 9 patients (15%). Of the 60 patients, 34 had a history of previous failed ipsilateral revascularization (56%), including open bypass for 8 (13%), endovascular for 8 (13%), and both open and endovascular intervention for 18 (30%). The endovascular-first approach procedures included catheter-directed thrombolysis only (n = 19; 3%), catheter-directed thrombolysis plus aspiration and/or rheolytic thrombectomy (n = 19; 32%), and aspiration and/or rheolytic thrombectomy (n = 16; 26%). Six patients (10%) underwent covered stent placement only. The underlying occlusive process was most often thrombosis of a previous bypass graft or stent in 32 patients (53%), followed by native vessel thrombosis in 15 (25%). ALI had resulted from embolism in 13 patients (21.7%), including 2 (3%) with embolization to occlude a previous bypass graft or stent. Technical success was achieved in 58 patients (97%), with open conversion required in two patients (3%). At 30 days postoperatively, 52 patients (87%) survived, and 53 (88%) had successful limb salvage. Five patients (8%) had required four-compartment fasciotomy. No major hemorrhagic complications developed. The median length of stay overall and in the intensive care unit was 9 days (interquartile range, 4-14 days) and 2 days (interquartile range, 1-5 days), respectively. At 1 year, the KM estimates were as follows: amputation-free survival, 58% ± 0.08%; limb salvage, 74.3% ± 0.07%; and survival, 73.3% ± 0.07%. The 1-year KM estimates for primary and secondary patency were 39.4% ± 0.08% and 78.2% ± 0.07%, respectively. On multivariable Cox regression analysis, only age independently predicted for death and/or amputation at the last follow-up (hazard ratio, 1.06; 95% confidence interval, 1.01-1.10; P = .01). CONCLUSIONS The current endovascular approaches to ALI have high technical success rates. Survival, limb salvage, perioperative complications, and length of stay were similar to those from previous reports of historical open cohorts. Further prospective, appropriately powered, multicenter cohort studies are warranted to evaluate the efficacy of endovascular vs open approaches to ALI.
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Affiliation(s)
- Olia Poursina
- Interdisciplinary Consortium on Advanced Motion Performance, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Hector Elizondo-Adamchik
- Interdisciplinary Consortium on Advanced Motion Performance, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Miguel Montero-Baker
- Division of Vascular Surgery and Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Zachary S Pallister
- Division of Vascular Surgery and Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Jayer Chung
- Division of Vascular Surgery and Endovascular Therapy, Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
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Wang Q, Zhu RM, Ren HL, Leng R, Zhang WD, Li CM. Combination of Percutaneous Rotational Thrombectomy and Drug-Coated Balloon for Treatment of Femoropopliteal Artery Nonembolic Occlusion: 12-Month Follow-up. J Vasc Interv Radiol 2020; 31:1661-1667. [PMID: 32921564 DOI: 10.1016/j.jvir.2020.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 03/10/2020] [Accepted: 03/15/2020] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To evaluate safety and efficacy of percutaneous mechanical thrombectomy using the Rotarex catheter combined with drug-coated balloon (DCB) in treatment of femoropopliteal artery occlusive disease. MATERIALS AND METHODS Between January 2016 and February 2018, 81 patients with acute or subacute femoropopliteal artery occlusions were treated with the Rotarex catheter combined with DCB. Lesions were classified according to the onset of symptoms as acutely (< 14 d) or subacutely (14 d to 3 mo) occluded. The mean lesion length was 12.1 cm ± 6.7. The primary endpoint was target lesion patency at 1 year as evaluated by duplex ultrasound (peak systolic velocity ratio < 2.4) and freedom from clinically indicated target lesion revascularization. Amputation rate, major adverse events, and ankle-brachial index at 12 months were evaluated. RESULTS Technical success rate was 100% (n = 81). Bailout stents were necessary in 14 patients owing to residual stenosis or flow-limiting dissection. Additional thrombolysis was applied in 10 interventions. No major adverse events occurred during hospital stay. There were 9 restenosis cases during the 12-month follow-up period. Primary patency rate was 87.3% (62/71), and freedom from target lesion revascularization rate was 90.1% (64/71). Ankle-brachial index significantly increased from 0.46 ± 0.15 to 0.77 ± 0.14 during follow-up. The amputation rate was 1.4% at 12 months. CONCLUSIONS These initial data from 2 centers suggest that the combination of the Rotarex catheter and DCB may be safe and effective for treatment of acute or subacute thrombotic femoropopliteal occlusion with superior immediate and midterm results achieved.
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Affiliation(s)
- Qi Wang
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, Gongren Tiyuchang Nanlu, Beijing 100020, China
| | - Ren-Ming Zhu
- Department of Vascular Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Hua-Liang Ren
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, Gongren Tiyuchang Nanlu, Beijing 100020, China
| | - Rui Leng
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, Gongren Tiyuchang Nanlu, Beijing 100020, China
| | - Wang-De Zhang
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, Gongren Tiyuchang Nanlu, Beijing 100020, China
| | - Chun-Min Li
- Department of Vascular Surgery, Beijing Chaoyang Hospital, Capital Medical University, Gongren Tiyuchang Nanlu, Beijing 100020, China.
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Natarajan B, Patel P, Mukherjee A. Acute Lower Limb Ischemia-Etiology, Pathology, and Management. Int J Angiol 2020; 29:168-174. [PMID: 33100802 DOI: 10.1055/s-0040-1713769] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Acute limb ischemia (ALI) is a vascular emergency associated with a high risk for limb loss and death. Most cases result from in situ thrombosis in patients with preexisting peripheral arterial disease or those who have undergone vascular procedures including stenting and bypass grafts. The other common source is cardioembolic. The incidence has decreased in recent times due to better anticoagulation strategies. Patients with suspected ALI should be evaluated promptly by a vascular specialist and consideration should be given for transfer to a higher level of care if such expertise is not available locally. Initial assessment should focus on staging severity of ischemic injury and potential for limb salvage. Neurological deficits can occur early and are an important poor prognostic sign. Duplex ultrasound and computed tomography angiography help plan intervention in patients with a still-viable limb and prompt catheter-based angiography is mandated in patients with an immediately threatened limb. Further investigations need to be pursued to differentiate embolic from thrombotic cause for acute occlusion as this can change management. Options include intravascular interventions, surgical bypass, or a hybrid approach. In this article, the authors discuss the common etiologies, clinical evaluation, and management of patients presenting with acute limb ischemia.
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Affiliation(s)
- Balaji Natarajan
- Department of Cardiology, University of California Riverside, School of Medicine, Riverside, California
| | - Prashant Patel
- Department of Cardiology, University of California Riverside, School of Medicine, Riverside, California
| | - Ashis Mukherjee
- Department of Cardiology, University of California Riverside, School of Medicine, Riverside, California
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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.
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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.
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Effectiveness and Safety of Percutaneous Thrombectomy Devices: Comparison of Rotarex and Angiojet in a Physiological Circulation Model. Eur J Vasc Endovasc Surg 2020; 59:983-989. [DOI: 10.1016/j.ejvs.2020.01.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 12/13/2019] [Accepted: 01/13/2020] [Indexed: 01/22/2023]
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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.
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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
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Contemporary Management of Acute Lower Limb Ischemia: Determinants of Treatment Choice. J Clin Med 2020; 9:jcm9051501. [PMID: 32429438 PMCID: PMC7291168 DOI: 10.3390/jcm9051501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/02/2020] [Accepted: 05/15/2020] [Indexed: 01/16/2023] Open
Abstract
The role of endovascular procedures in the treatment of acute lower limb ischemia (ALI) is expanding. For treatment, the choice between surgical or endovascular is still debated. The aim of this study was to identify factors that determine the selection of treatment. This study included 307 ALI patients (209 with thrombosis). Patient details, factors affecting the procedure choice, and outcomes were analyzed. The majority of patients were operated on (52.4%). Surgery was more frequent in embolic patients with embolus (odds ratio (OR) 33.85; 95% confidence interval (CI) 6.22–184.19, p < 0.0001), severe ischemia (OR 1.79; 95% CI 1.2–2.66, p = 0.0041), and active cancer (OR 4.99; 95% CI 1.26–19.72, p = 0.02). Tibial arteries involvement was negatively related to surgery (OR 0.25; 95% CI 0.06–0.95, p = 0.04). The complications and amputation rates were comparable. Reinterventions were more common in the endovascular group (19 (20.2%) vs. 17 (8.9%), p = 0.007). The six-month mortality was higher in the operated patients (12.6% vs. 3.2%, respectively, p = 0.001). The determinants of the treatment path are ischemia severity, concurrent cancer, embolus, and peripheral lesion location. Modification of the Rutherford acute lower limb ischemia classification is required to improve the decision-making in patients with profound ischemia.
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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.
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Bath J, Hartwig J, Dombrovskiy VY, Vogel TR. Trends in management and outcomes of vascular emergencies in the nationwide inpatient sample. VASA 2020; 49:99-105. [DOI: 10.1024/0301-1526/a000791] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Summary: Background: To evaluate trends in frequency, mortality and treatment for non-traumatic vascular emergencies (VE) in the US. Methods: VE in the Nationwide Inpatient Sample (2005–2014) were identified. ICD-9 CM diagnosis and procedures codes captured six common VE. Results: 228,210,504 emergency admissions with 317,396 procedures for VE were estimated. Mean age was 67.8 years and were primarily men (56.1 %; p < 0.0001). The commonest VE was Acute Limb Ischemia (ALI) (82.4 %) followed by ruptured AAA (10.8 %) and Acute Mesenteric Ischemia (4.71 %). VE increased from 132.8 per 100,000 admissions in 2005 to 153.6 in 2014 (p < 0.001), with mortality decrease for all VE (13.8 % vs. 9.1 %; p < 0.0001). Length of stay decreased (median 8 vs. 7 days; p < 0.0001) but cost of care increased (median $ 25,443 vs. $ 29,353; p < 0.0001). Endovascular treatment increased overall for VE from 23.7 % in 2005 to 37.2 % in 2014 (p < 0.0001). Hospital mortality for VE decreased overall, except ruptured thoracoabdominal aortic aneurysm with mortality decrease with endovascular treatment (34.3 vs. 11.1; p = 0.04) and mortality increase with open treatment (44.7 vs. 47.6; p = 0.06). ALI overall mortality decreased from 8.1 % to 5.7 % (p < 0.0001) due to reduced open surgical mortality from 9.6 % to 7.4 % (p < 0.0001); endovascular mortality did not improve over time (4.0 % vs. 3.4 %; p = 0.45). Hospital mortality also increased for endovascular treatment of ruptured thoracic aortic aneurysm (rTAA) from 14.9 % to 27.4 % (p = 0.0003) during this period. Conclusions: VE frequency increased with a decrease in overall mortality over time. Overall hospital stay has decreased but with an increase in the cost of care. Open surgical mortality for VE has also decreased overall, suggesting perioperative care improvements, with the exception of ruptured thoracoabdominal aortic aneurysm. Endovascular utilization for VE has significantly increased; associated with lower mortality for most VE, although an increase in hospital mortality after endovascular repair of rTAA was seen. This may be due to an increased implementation of endovascular repair for patients not previously eligible for surgery due to high risk. We recommend careful selection of patients for rTAA treatment as mortality has increased despite endovascular therapy and at an increased cost of care.
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Affiliation(s)
- Jonathan Bath
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri, USA
| | - Jacob Hartwig
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri, USA
| | - Viktor Y. Dombrovskiy
- Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Todd R. Vogel
- Division of Vascular Surgery, University of Missouri, School of Medicine, Columbia, Missouri, USA
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Kolte D, Kennedy KF, Shishehbor MH, Mamdani ST, Stangenberg L, Hyder ON, Soukas P, Aronow HD. Endovascular Versus Surgical Revascularization for Acute Limb Ischemia: A Propensity-Score Matched Analysis. Circ Cardiovasc Interv 2020; 13:e008150. [PMID: 31948292 DOI: 10.1161/circinterventions.119.008150] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The optimal revascularization strategy for acute limb ischemia (ALI) remains unclear, and contemporary comparative effectiveness data on endovascular versus surgical revascularization are lacking. METHODS We used the 2010 to 2014 National Inpatient Sample databases to identify hospitalizations with a primary diagnosis of ALI. Patients were propensity-score matched on the likelihood of undergoing endovascular versus surgical revascularization using a logistic regression model. The primary outcome was in-hospital mortality. Secondary outcomes included myocardial infarction, stroke, composite of death/myocardial infarction/stroke, any amputation, fasciotomy, acute kidney injury, major bleeding, transfusion, vascular complications, length of stay, and hospital costs. RESULTS Of 10 484 (weighted national estimate=51 914) hospitalizations for ALI, endovascular revascularization was performed in 5008 (47.8%) and surgical revascularization in 5476 (52.2%). In the propensity-score matched cohort (n=7746; 3873 per group), patients who underwent endovascular revascularization had significantly lower in-hospital mortality (2.8% versus 4.0%; P=0.002), myocardial infarction (1.9% versus 2.7%; P=0.022), composite of death/myocardial infarction/stroke (5.2% versus 7.5%; P<0.001), acute kidney injury (10.5% versus 11.9%; P=0.043), fasciotomy (1.9% versus 8.9%; P<0.001), major bleeding (16.7% versus 21.0%; P<0.001), and transfusion (10.3% versus 18.5%; P<0.001), but higher vascular complications (1.4% versus 0.7%; P=0.002), compared with those undergoing surgical revascularization. Rates of any amputation were similar between the 2 groups (4.7% versus 5.1%; P=0.43). Median length of stay was shorter and hospital costs higher with endovascular versus surgical revascularization. CONCLUSIONS In patients with ALI, endovascular revascularization was associated with better in-hospital clinical outcomes compared with surgical revascularization. Contemporary randomized controlled trials are needed to determine the optimal revascularization strategy for ALI.
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Affiliation(s)
- Dhaval Kolte
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston (D.K.)
| | - Kevin F Kennedy
- Statistical Consultant, Lifespan Cardiovascular Institute, Providence, RI (K.F.K.)
| | - Mehdi H Shishehbor
- Division of Cardiovascular Medicine, Case Western Reserve University and University Hospitals, Cleveland, OH (M.H.S.)
| | - Shafiq T Mamdani
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI (S.T.M., O.N.H., P.S., H.D.A.)
| | - Lars Stangenberg
- Division of Vascular Surgery, Warren Alpert Medical School of Brown University, Providence, RI (L.S.)
| | - Omar N Hyder
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI (S.T.M., O.N.H., P.S., H.D.A.)
| | - Peter Soukas
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI (S.T.M., O.N.H., P.S., H.D.A.)
| | - Herbert D Aronow
- Division of Cardiology, Lifespan Cardiovascular Institute, Warren Alpert Medical School of Brown University, Providence, RI (S.T.M., O.N.H., P.S., H.D.A.)
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George EL, Colvard B, Ho VT, Rothenberg KA, Lee JT, Stern JR. Real-World Outcomes of EKOS Ultrasound-Enhanced Catheter-Directed Thrombolysis for Acute Limb Ischemia. Ann Vasc Surg 2020; 66:479-485. [PMID: 31917220 DOI: 10.1016/j.avsg.2019.12.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/30/2019] [Accepted: 12/30/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Ultrasound-enhanced catheter-directed thrombolysis (UET) using the Ekosonic® Endovascular System device for acute, peripheral arterial ischemia has been purported in clinical trials to accelerate the fibrinolytic process to reduce treatment time and lytic dosage. We aim to describe outcomes of UET in a real-world clinical setting. METHODS We performed a retrospective review of all patients undergoing UET for acute limb ischemia at a single institution. Data collected included patient demographics, procedural details, and 30-day and 1-year outcomes. The primary endpoints for analysis were major adverse limb events (MALEs; reintervention and/or amputation) and mortality within 30-days and 1-year. Secondary endpoints included technical success, use of adjunctive therapies, and postoperative complications. RESULTS A total of 32 patients (mean age 67.4 ± 14.9 years; 25% women) underwent UET for acute limb ischemia between 2014 and 2018. The Rutherford Acute Limb Ischemia Classification was Rutherford (R) 1 in 56.3%, R2a in 31.3%, and R2b in 12.5%. Etiology was thrombosis of native artery in 12.5% of patients, prosthetic bypass in 31.3%, autogenous bypass in 6.3%, and stented native vessel in 50.0%. Mean duration of thrombolytic therapy was 22.2 ± 11.3 hr, and mean tissue plasminogen activator dose was 24.5 ± 15.3 mg. MALEs occurred in 16.7% of patients within the first 30 days and 38.9% experienced a MALE by 1 year. Limb salvage at 30 days and 1 year was 93.8% and 87.5%, respectively. Ipsilateral reintervention was required in 12.5% of patients within 30 days and 37.5% of patients within 1 year. Overall mortality was 6.2% at 30 days and 13.5% at 1 year. In-line flow to the foot was re-established in 90.6% of patients, with a significant improvement in preoperative to postoperative ankle-brachial index (0.31 ± 0.29 vs. 0.78 ± 0.34, P < 0.001) and number of patent tibial runoff vessels (1.31 ± 1.20 vs. 1.96 ± 0.86, P < 0.001). There was no significant difference in revascularization success between occluded vessel types. All but one patient required adjunctive therapy such as further thromboaspiration, stenting, or balloon angioplasty. Major bleeding complications occurred in 3 patients (9.4%), including 1 intracranial hemorrhage (3.1%). CONCLUSIONS UET with the EKOS device demonstrates acceptable real-world outcomes in the treatment of acute limb ischemia. UET is generally safe and effective at re-establishing in-line flow to yield high limb salvage rates. However, UET is associated with a high rate of reintervention. Further investigation is needed into specific predictors of limb salvage and need for reintervention, as well as cost-efficacy of this technology compared with that of traditional methods.
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Affiliation(s)
- Elizabeth L George
- Division of Vascular & Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Benjamin Colvard
- Division of Vascular & Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Vy-Thuy Ho
- Division of Vascular & Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Kara A Rothenberg
- Department of Surgery, University of California San Francisco, East Bay, Oakland, CA
| | - Jason T Lee
- Division of Vascular & Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jordan R Stern
- Division of Vascular & Endovascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA.
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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: 230] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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de Athayde Soares R, Matielo MF, Brochado Neto FC, Pereira de Carvalho BV, Sacilotto R. Analysis of the Safety and Efficacy of the Endovascular Treatment for Acute Limb Ischemia with Percutaneous Pharmacomechanical Thrombectomy Compared with Catheter-Directed Thrombolysis. Ann Vasc Surg 2019; 66:470-478. [PMID: 31863953 DOI: 10.1016/j.avsg.2019.11.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/11/2019] [Accepted: 11/25/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND To evaluate the rates of limb salvage, survival, and perioperative mortality in patients with acute limb ischemia (ALI) submitted to endovascular revascularization with pharmacomechanical thrombectomy (PMT) and catheter-directed thrombolysis (CDT). METHODS This was a retrospective consecutive cohort study of patients with ALI who were submitted to endovascular treatment with PMT or fibrinolysis at the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual (São Paulo, Brazil), between July 2015 and December 2018. The limb salvage rate and survival rate at 720 days were analyzed in both the PMT (group 1) and CDT treatment (group 2), as well as the perioperative mortality rate (PMR) at 30 days after surgery. RESULTS One hundred twelve patients were admitted to the emergency department with ALI between July 2015 and December 2018. Seventeen patients diagnosed with Rutherford III irreversible ALI and 46 patients submitted to open surgery were excluded. Thus, 49 patients were submitted to endovascular surgery; 18 (36.7%) were classified into group 1, and 31 (63.3%) were classified into group 2. The clinical data were equal between the 2 groups, but there was a higher prevalence of thrombophilia in group 1 (3 cases; P < 0.001). The limb salvage rate and the overall survival rate at 720 days were similar between groups 1 and 2 (87.8% vs. 89.7%, P = 0.78 and 84.7% vs. 69.2%, P = 0.82, respectively). There was no statistical difference regarding secondary patency rates at 720 days between groups 1 and 2 (group 1, 81.9% and group 2, 78.8%; P = 0.66). The PMR was 16.7% (8 patients) within the first 30 days. Group 2 had a higher overall mortality rate (OMR) (6 patients, 19.3%, P = 0.03). Regarding the PMT group, there was a higher rate of complications such as myoglobinuria, hematuria, acute renal failure, and death in the subgroup of patients in whom there were performed more than 150 cycles/sec during the surgery (P < 0.001). CONCLUSIONS In the present study, the PMT and CDT endovascular procedures had similar limb salvage, overall survival, and secondary patency rates. However, the OMR was higher in the CDT group. Another important finding was related to the number of cycles/sec performed in the PMT group, in whom patients with more than 150 cycles/sec have presented with higher rates of hematuria, myoglobinuria, acute renal failure, and death.
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Affiliation(s)
- Rafael de Athayde Soares
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de, São Paulo, Brazil.
| | - Marcelo Fernando Matielo
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de, São Paulo, Brazil
| | | | | | - Roberto Sacilotto
- Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de, São Paulo, Brazil
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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.
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Preliminary Experience of Viabahn Stent Graft Inside the Occluded Prosthetic Bypass Graft for the Treatment of Above Knee Femoropopliteal Bypass Occlusion. Cardiovasc Intervent Radiol 2019; 43:223-230. [DOI: 10.1007/s00270-019-02376-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
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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.
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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
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Vakhitov D, Hakovirta H, Saarinen E, Oksala N, Suominen V. Prognostic risk factors for recurrent acute lower limb ischemia in patients treated with intra-arterial thrombolysis. J Vasc Surg 2019; 71:1268-1275. [PMID: 31495677 DOI: 10.1016/j.jvs.2019.07.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 07/10/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of this study was to assess factors predisposing patients to recurrent acute lower limb ischemia (RALLI). METHODS Acute lower limb ischemia patients treated with catheter-directed thrombolysis (CDT) at Tampere University Hospital and Turku University Hospital between March 2002 and December 2015 were included. The patients' baseline demographics, comorbidities, and other characteristics were assessed retrospectively. Significant factors revealed by univariable analysis were tested in a multivariable model for associations with RALLI. A patency analysis was performed, and the risks of reocclusion were identified. The limb salvage rates after reocclusion were evaluated. RESULTS Altogether, 303 consecutive patients with a mean age of 71 years (standard deviation, 11.8 years) were included. Of them, 159 (52.5%) were men. A total of 164 (54.1%) native arterial and 139 (45.9%) bypass graft occlusions were initially treated with CDT. On completion of CDT, 204 additional endovascular or conventional surgical procedures on 203 patients were performed to obtain adequate distal perfusion. During a median follow-up of 40 months (interquartile range, 69 months), 40 (24.4%) cases of RALLI occurred in native arteries and 90 (64.7%) in bypass graft patients (P < .001). In native arteries, the absence of appropriate anticoagulant and antiplatelet medication was independently associated with the development of acute reocclusions (hazard ratio, 6.51) in the Cox multivariable regression analysis. The patency rates were 86.6%, 72.2%, and 68.0% at 1 year, 5 years, and 9 years, respectively. In bypass grafts, worsened tibial runoff (crural index III: hazard ratio, 2.40) was independently associated with RALLI. The respective patency rates were 60.5%, 34.0%, and 29.2% for synthetic conduits and 30.8%, 20.5%, and 13.7% for autologous vein grafts at 1 year, 5 years, and 9 years. Altogether, 38 (29.2%) major amputations were performed on patients with reocclusions. Patients with synthetic conduits demonstrated superior limb salvage rates after reocclusion in comparison to native arteries or vein grafts (P = .025). CONCLUSIONS Appropriate post-thrombolytic antiplatelet or anticoagulant treatment after native arterial events is of great importance, but additional data are needed to improve treatment algorithms. Adequate outflow in bypass graft patients is crucial. Patients with prosthetic bypass grafts have superior limb salvage rates after reocclusion.
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Affiliation(s)
- Damir Vakhitov
- Center for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland.
| | - Harri Hakovirta
- Department of Vascular Surgery, Turku University Hospital, Turku, Finland
| | - Eva Saarinen
- Center for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Niku Oksala
- Center for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland; Department of Surgery, Faculty of Medicine and Health Technology, Tampere University Hospital, Tampere, Finland; Finnish Cardiovascular Research Center Tampere, Tampere, Finland
| | - Velipekka Suominen
- Center for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
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Veenstra EB, van der Laan MJ, Zeebregts CJ, de Heide EJ, Kater M, Bokkers RPH. A systematic review and meta-analysis of endovascular and surgical revascularization techniques in acute limb ischemia. J Vasc Surg 2019; 71:654-668.e3. [PMID: 31353270 DOI: 10.1016/j.jvs.2019.05.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The initial treatment of patients with acute limb ischemia (ALI) remains undefined. The aim of this article was to compare the safety and effectiveness of catheter-driven thrombolysis (CDT) with surgical revascularization and evaluate the various fibrinolytic agents, endovascular, and pharmacochemical approaches that aim for thrombectomy. METHODS PubMed, Embase, and the Cochrane Library were searched for studies on the management of ALI by means of surgical or endovascular recanalization, returning 520 studies. All randomized, controlled trials, nonrandomized prospective, and retrospective studies were included comparing treatment of ALI. RESULTS Twenty-five studies, investigating a total of 4689 patients, were included for meta-analysis spread across nine different comparisons. No differences were found in limb salvage between thrombectomy and thrombolysis. More major vascular events were seen in the thrombolysis group (6.5% compared with 4.4% in the surgically treated group; odds ratio [OR], 0.33; 95% confidence interval [CI], 0.13-0.87; P = .02; I2 = 20%). Comparable limb salvage was found for high- and low-dose recombinant tissue plasminogen activator (r-tPA). No significant differences were found in major vascular event between low r-tPA (14%) and high r-tPA (10.5%; P = .13). The 30-day limb salvage rate was 79.7% for r-tPA treatment and 60.4% for streptokinase (OR, 3.14; 95% CI, 1.26-7.85; P = .01; I2 = 0%). AngioJet showed more limb salvage at 6 months compared with r-tPa (OR, 2.21; 95% CI, 1.17-4.18; P = .01; I2 = 0%). CONCLUSIONS Both CDT and surgery have comparable limb salvage rates in patients with ALI; however, CDT is associated with a higher risk of hemorrhagic complications. No conclusions can be drawn regarding the risk of hemorrhagic complications regarding thrombolytic therapy by means of r-tPA, streptokinase, or urokinase. Insufficient data are available to conclude the preference of using a hybrid approach, ultrasound-accelerated CDT, heated r-tPA. or novel endovascular (rheolytical) thrombectomy systems. Future trials regarding ALI need to be constructed carefully, ensuring comparable study groups, and should follow standardized practices of outcome reporting.
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Affiliation(s)
- Emile B Veenstra
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands; Faculty of Medical Sciences, University of Groningen, Groningen, The Netherlands
| | - Maarten J van der Laan
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Erik-Jan de Heide
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Matthijs Kater
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands.
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Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FGR, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RAG, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; 69:e71-e126. [PMID: 27851992 DOI: 10.1016/j.jacc.2016.11.007] [Citation(s) in RCA: 438] [Impact Index Per Article: 87.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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50
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de Athayde Soares R, Matielo MF, Brochado Neto FC, Cury MVM, Duque de Almeida R, de Jesus Martins M, Pereira de Carvalho BV, Sacilotto R. Analysis of the results of endovascular and open surgical treatment of acute limb ischemia. J Vasc Surg 2019; 69:843-849. [DOI: 10.1016/j.jvs.2018.07.056] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/11/2018] [Indexed: 11/29/2022]
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