Sheath-shunt technique for avoiding lower limb ischemia during complex endovascular aneurysm repair

The Role of Endovascular Repair of Popliteal Arterial Injuries in the Acute Setting

OBJECTIVES

The role of endovascular surgery in the treatment of popliteal arterial injuries is not well established. As with other popliteal pathology, open repair has traditionally been considered the gold standard. As data has accumulated and technology advanced, however, a reassessment of the role of endovascular surgery is warranted. The aim of this study is to perform a noninferiority comparison of open versus endovascular management of traumatic popliteal injuries. Our hypothesis is that endovascular management is noninferior to open management of traumatic popliteal injuries.

METHODS

The National Trauma Data Bank was searched for adult patients from 2002-2016 for isolated popliteal arterial injury. The study used a standard noninferiority methodology to compare rates of amputation and compartment syndrome between endovascular and open surgery. Margins for noninferiority were established using established published rates of complications: 17.1% for amputations and 23.0% for compartment syndrome. Endovascular intervention would be considered noninferior to open surgery if the lower bound confidence of the complication proportion (endo/open complication rate) was greater than the pre-defined noninferiority margin.

RESULTS

3698 patients met inclusion criteria, with blunt injury accounting for 2117 (57%) and penetrating injury accounting for 1581 (43%). Within the blunt group, 1976 (93.3%) underwent open and 141 (6.7%) endovascular surgery. The rate of compartment syndrome (percentage and 95% confidence interval) after surgery for open repair was 9.9 (8.6-11.2) and 6.4 (3.2-11.3) for endovascular repair. The complication proportion is 64.6 (59.7-69.5). The rate of amputation for open repair was 15.7 (14.2-17.4) and 14.2 (9.2-20.6) for endovascular repair. The complication proportion is 90.4 (87.4-93.4). Within the penetrating group, 1525 (96.5%) underwent open repair and 56 (3.5%) endovascular surgery. The rate of compartment syndrome after surgery for open repair was 14.9 (13.2-16.7) and 5.4 (1.5-13.6) for endovascular repair. The complication proportion is 36.2 (31.3-41.1). The rate of amputation for open repair was 4.3 (3.3-5.4) and 3.6 (0.7-11.0) for endovascular repair. The complication proportion is 83.7 (75.3-90.6).

CONCLUSION

These data suggest that endovascular repair of popliteal artery injury may be noninferior to open repair with respect to limb preservation . Further examination of endovascular repair in popliteal artery injury is warranted.

Distal perfusion cannulae reduce extracorporeal membrane oxygenation-related limb ischemia

BACKGROUND

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a means of providing cardiopulmonary support that is being increasingly used in patients with acute heart failure. When ECMO cannulae are placed peripherally, their large diameters pose a risk of limb ischemia. Distal perfusion cannulae (DPC) have been proposed as means to reduce risk, but their use is not recommended by the most recent ECMO guidelines. We sought to establish their utility at our institution.

METHODS

We performed a retrospective review of of all patients treated with peripheral VA-ECMO at our institution from 2013-2018. During the first 2 years, DPC were not routinely placed, whereas in the final 4 years, DPC were recommended as part of the ECMO cannulation routine.

RESULTS

One hundred and one patients were treated with peripheral VA-ECMO, with an overall mortality of 61%. By univariate analysis, obesity (47% vs. 75%, P<0.01) and limb ischemia (57% vs. 83%, P<0.05) were associated with increased mortality. DPC were placed prophylactically in 49% of patients. Prophylactic placement of a DPC at the time of cannulation significantly reduced the incidence of limb ischemia (2% vs. 32%, P<0.05), but did not impact mortality (53% vs. 69%, P=0.0953). In patients who did not have a DPC placed during ECMO cannulation and subsequently developed limb ischemia, late DPC placement for limb salvage did not impact mortality.

CONCLUSIONS

Limb ischemia portends a poor outcome in VA-ECMO patients, and prophylactic DPC placement significantly reduces the risk of limb ischemia. We propose prophylactic DPC placement be considered in patients requiring peripheral VA-ECMO.

Development of a Puncture Technique for Implanting Temporary Vascular Shunts in a Porcine Model

BACKGROUND

Temporary vascular shunts (TVSs) are an effective tool for rapidly restoring blood flow to a limb or organ that has experienced vascular injury and ischemia and for which revascularization is not an immediate option. Usually, through an opening in the skin, the TVS is positioned within the proximal and distal stumps of the injured vessel, restoring perfusion and stopping the ischemia. The aim of this study is to compare standard TVS technique and a developed puncture technique for implanting TVS and to evaluate the utility and feasibility of this protocol after arterial lesions, in pigs.

METHODS

Vascular injuries were inflicted in both hind limbs of 30 pigs, and vascular interventions were performed, using standard and puncture TVS. Because each pig was implanted with both types of TVSs, it was possible to simultaneously monitor, analyze, and compare parameters such as, the mean arterial pressure (MAP, in mm Hg), blood flow (mL/min), and insertion times, in the same animal.

RESULTS

It was observed that the MAP in the limbs recovered and approached systemic MAP, in 100% of the experiments, in both groups. Analysis of the blood flow data showed that this parameter was significantly reduced in the puncture TVS group (110.36 ± 9.99 mL/min vs. 153.20 ± 18.57 mL/min, P = 0.001). On the other hand, the insertion time for the standard TVS was significantly greater than that of the puncture shunt (15.32 ± 3.08 min vs. 10.37 ± 1.7 min, P = 0.001). Furthermore, it was found that the primary and secondary patency and complication rates were similar for both TVS types.

CONCLUSION

Thus, given the adequate MAP recovery and reduction in implantation time observed in this experimental and in an animal model study, the use of the puncture TVS technique is effective and feasible.

Combined interventional and surgical treatment of tandem middle cerebral artery embolus and internal carotid artery occlusion: case report

Tandem internal carotid artery (ICA) origin occlusion and middle cerebral artery (MCA) thromboembolism is a life-threatening condition with poor neurological outcome. The authors report on a patient presenting with acute ischemic stroke from a tandem ICA and MCA occlusion with penumbra. Emergency MCA mechanical thrombectomy was performed through percutaneous cervical ICA access due to the inability to cross the cervical carotid occlusion. Emergency carotid endarterectomy to reperfuse the poorly collateralized hemisphere and repair the ICA access site was performed 2 hours after completion of tissue plasminogen activator (tPA) infusion. This case illustrates the shortest reported interval between tPA infusion and open surgical intervention for carotid revascularization, as well as the role of direct carotid artery access for mechanical thrombectomy. The authors also describe the use of a temporizing femoral artery-to-ICA shunt to maintain cerebral perfusion in the setting of ICA occlusion.