Open surgical or endovascular revascularization for acute limb ischemia

Single Center Experience with the JETi Hydrodynamic Thrombectomy System for Acute Limb Ischemia

OBJECTIVE

Acute limb ischemia (ALI) remains a vascular emergency with high morbidity and mortality. While the JETi Hydrodynamic Thrombectomy System (Abbott, Abbott Park, IL) offers a percutaneous approach to fragment and aspirate thrombus in patients with arterial occlusions, data on its efficacy and safety is limited. This study reports our early experience using the JETi device to treat ALI at our institution.

METHODS

This is a single-center retrospective review of ALI patients treated with the JETi device between September 2020 and December 2022. Patients were included if the JETi device was used either as primary intervention or as an adjunct procedure. The primary endpoint was technical success defined as <50% residual thrombus post-intervention. Secondary endpoints included achieving complete resolution of the thrombus on angiogram, acute kidney injury (AKI), major bleeding, 30-day major amputation, and 30-day mortality.

RESULTS

A total of 59 JETi procedures for ALI (mean age 62 years [IQR 56,71]) were performed on 39 males and 20 females. Median time from onset of symptoms to hospitalization was 24 hours (IQR 4-168). Rutherford classifications were I (10), IIa (27), IIb (14) and undocumented (8). Etiology of ALI was native vessel thrombosis (27), embolism (16), graft/stent thrombosis (14), and iatrogenic (2). A total of 124 vessels were treated, with an average of 2.1 vessels per procedure. The primary outcome was achieved in 86% (107/124) of the arteries, with 82% (102/124) successfully opened using the JETi device alone without the need for any adjunctive therapy. Complete resolution of the thrombus using JETi was achieved in 81% (101/124) arteries, with or without the use of adjunctive therapy. 6.7% (4/59) of patients required a major limb amputation within 30 days despite successful recanalization, and one 30-day mortality was recorded. Complications included distal embolization (5), access site hematoma (2), and acute kidney injury (4). No major bleeding, hemolysis-induced AKI, or vessel dissection or perforation were observed.

CONCLUSION

The JETi device appears to be a safe and effective percutaneous treatment option in the management of ALI. It provides definitive treatment with a high technical success rate of 86% and a good safety profile.

Patients with Acute Lower Limb Ischemia Continue to Have Significant Morbidity and Mortality

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.

Editor's Choice -- Survival, Limb Salvage, and Management of Patients with Lower Limb Acute Ischaemia: A French National Retrospective Observational Study

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.

Super-Elderly Case of Acute Lower Limb Ischemia Treated with Indigo Aspiration System in Japan

The Indigo Aspiration System (Penumbra Ltd., Alameda, CA, USA), a catheter-based device intended for the endovascular removal of clots from peripheral arteries and veins, was launched in Japan to treat acute limb ischemia after the cessation of urokinase sales. The initial application of this system in Japan was on a 96-year-old male patient. He was diagnosed with acute lower limb ischemia, which was caused by an embolism from a left common iliac artery aneurysm. The treatment significantly enhanced the perfusion to his left foot. This case report elaborates on the patient's treatment experience and discusses the indications for using the device.

Outcomes After Open Surgical, Hybrid, and Endovascular Revascularization for Acute Limb Ischemia

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.

Sex-Related Disparities in Acute Limb Ischemia Treatment Outcomes

BACKGROUND

Although a substantial impetus behind disparities research in healthcare exists, those that are sex-related within vascular surgery outcomes are largely unexplored. Consequently, published guidelines lack specificity when it comes to treating male and female patients with vascular disease. Disparities related to patients suffering from chronic limb-threatening ischemia have been broached, although no extensive studies assessing disparities in acute limb ischemia treatment outcomes have come to the forefront. In this study, our aim is to identify and quantify sex-related disparities as they pertain to interventions for acute limb ischemia.

METHODS

Using the TriNetX global research network, we conducted a multicenter query across 48 healthcare organizations spanning 5 countries for patients treated for acute limb ischemia. We determined the number of male and female patients that received one of the following interventions: open revascularization, percutaneous mechanical thrombectomy, or catheter-directed thrombolysis and/or adjunctive endovascular procedures. Propensity score matching was performed to account for comorbidities. Risk of adverse outcomes within 30 days was calculated for each sex, including reintervention, major amputation, and death. Risk of adverse outcomes was then compared between treatment groups of the same sex and between sexes. Type-I errors were reduced through utilization of the Holm-Bonferroni method to correct P values.

RESULTS

Within our study, we noted several important findings. Females were more likely to receive catheter-directed thrombolysis and/or adjunctive endovascular procedures (P = 0.001) than males. There were no significant differences in the rates of open revascularization or percutaneous mechanical thrombectomy between males and females. Overall, females were more likely to die within 30 days (P < 0.0001) and greater number of males required reintervention within 30 days (P < 0.0001). Analyzing outcomes within individual treatment groups, females undergoing open revascularization or catheter-directed thrombolysis and/or adjunctive endovascular intervention demonstrated a profound increase in mortality within 30 days of intervention (P = 0.0072 and P = 0.0206, respectively), but these differences were not reflected in the percutaneous mechanical thrombectomy group. Limb salvage rates in females were higher than males overall although there were no significant sex differences within any treatment groups specifically.

CONCLUSIONS

In conclusion, there was a significantly higher risk of death in females across all treatment groups in the studied timeframe. Limb salvage rates were higher for females in the open revascularization (OR) treatment group, while males were more likely to require a reintervention across all treatment groups. By evaluating these disparities, we can provide greater insight into personalized treatment for patients presenting with acute limb ischemia.

Patients with Acute Limb Ischemia Might Benefit from Endovascular Therapy-A 17-Year Retrospective Single-Center Series of 985 Patients

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.

Contextualizing the BEST-CLI Trial Results in Clinical Practice

Background

Chronic limb-threatening ischemia (CLTI) is associated with poor long-term outcomes. Although prompt revascularization is recommended, the optimal revascularization strategy remains uncertain. The BEST-CLI trial compared endovascular and open surgical revascularization for CLTI, but the generalizability of this study to the clinical population with CLTI has not been evaluated.

Methods

We included Medicare beneficiaries aged 65-85 years with CLTI who underwent revascularization and would be eligible for enrollment in BEST-CLI between 2016 and 2019. The primary exposure was type of revascularization (endovascular vs autologous graft [cohort 1] vs nonautologous graft [cohort 2]), and the primary outcome was a composite of major adverse limb events (MALE) and death. MALE included above-ankle amputation and major intervention, which was defined as new bypass of index limb, thrombectomy, or thrombolysis.

Results

A total of 66,153 patients were included in this study (10,125 autologous grafts; 7867 nonautologous grafts; 48,161 endovascular). Compared with those enrolled in BEST-CLI cohort 1, patients in this study were older (mean age, 73.5 ± 5.7 vs 69.9 ± 9.9 years), more likely to be female (38.3% [22,340/58,286] vs 28.5% [408/1434]), and presented with more comorbidities. Endovascular operators for the study population vs BEST-CLI cohort 1 were less likely to be surgeons (55.9% [26,924/48,148] vs 73.0% [520/708]) and more likely to be cardiologists (25.5% [5900/48,148] vs 14.5% [103/78]). When assessing long-term outcomes, the crude risk of death or MALE in this cohort was higher with surgery (56.6% autologous grafts vs 42.6% BEST-CLI cohort 1 at a median of follow-up 2.7 years; 51.6% nonautologous grafts vs 42.8% BEST-CLI cohort 2 at a median follow-up of 1.6 years) but similar with the endovascular cohort (58.7% Medicare vs 57.4% cohort 1 at 2.7 years; 47.0% Medicare vs 47.7% cohort 2 at 1.6 years). Of those who received endovascular treatment, the risk of incident major intervention was less than half in this cohort compared with the trial cohort (10.0% Medicare vs 23.5% cohort 1 at 2.7 years; 8.6% Medicare vs 25.6% cohort 2 at 1.6 years), although technical endovascular failures were not captured.

Conclusions

These results suggest that the findings of the BEST-CLI trial may not be applicable to the entirety of the Medicare population of patients with CLTI undergoing revascularization.

What Is the Best Treatment for Acute Limb Ischemia?

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.

High Rates of Recurrent Revascularization in Acute Limb Ischemia - a National Surgical Quality Improvement Program Study

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.

A case report of distal radial puncture in a patient with acute upper limb ischaemia: the last hope of the cardiologist?

Background

Patients with acute limb ischaemia (ALI) present with acute symptoms, requiring prompt diagnosis and expedited treatment to preserve the viability of the affected ischaemic tissue.

Case summary

We present an 83-year-old female patient with upper ALI due to thrombotic occlusion of the left brachial artery. Concomitantly, the patient had a first diagnosis of atrial fibrillation and was not on treatment with oral anticoagulation. Transfemoral thrombectomy using a 6F Rotarex® catheter resulted in removal of the thrombus from the brachial artery. However, significant amounts of debris embolized distally, causing occlusion of both the radial and ulnar arteries. The debris was successfully removed after puncture of the distal radial artery and retrograde thrombus aspiration using a 5F Envoy catheter. This manoeuver led to flow restoration in both the radial and ulnar arteries and to complete resolution of ischaemic symptoms of the patient.

Discussion

Interventionists may consider distal radial puncture not only as an access site for coronary angiography but also as an option for the endovascular management of ALI in cases of cardiac embolism, as described herein or in cases of thrombotic complications during routine catheterization and percutaneous coronary intervention. Herein, we describe the case of an 83-year-old patient, who presented with acute upper limb ischaemia. Due to embolization of thrombotic debris during Rotarex® catheter thrombectomy, flow further diminished in the ulnar and radial arteries. The last hope for successful interventional treatment was thrombectomy from distally after retrograde puncture of the distal radial artery. This unique manoeuver led to flow restoration and complete recovery of the patient without the need for open surgery.

Mechanisms and Interventions on Acute Lower Limb Ischemia/Reperfusion Injury: A Review and Insights from Cell to Clinical Investigations

AIM

This review aims to highlight mechanistic insights on skeletal muscle ischemia/reperfusion injury (IRI), a potentially life-threatening complication after acute lower limb ischemia. Lower limb IRI produces a wide spectrum of manifestations, ranging from local skeletal muscle necrosis to multi-organ failure. There is increasing evidence from both in vitro and in vivo reports to demonstrate several promising interventions that have successfully reduced IRI in skeletal muscle ischemic models. However, clinical studies to confirm their benefits are still lacking.

METHOD

We conducted a comprehensive search of English literature listed in the PubMed database (All related published articles shown in PubMed until September 2020 have been included in this review), using the following keywords: acute limb ischemia, acute arterial occlusion, compartment syndrome, ischemic reperfusion injury, revascularization and hypoxic reoxygenation.

RESULT

58 articles pertinent to acute limb ischemia models were identified. The underlying mechanisms associated with IRI in skeletal muscle are due to excessive mitochondrial production of reactive oxygen species (ROS), cellular apoptosis and activation of inflammatory cascades. Several therapeutic interventions including both pharmacological and non-pharmacological treatments have been investigated and some showed promising results. These interventions include antioxidation, anti-inflammation, anti-hypertension, controlled-reperfusion and ischemic preconditioning. Further clinical studies are needed to warrant their use in a clinical setting for lower limb IRI treatment.

CONCLUSION

This review comprehensively summarizes the mechanisms underlying IRI in lower limb ischemia. The reports currently available regarding the potential therapeutic interventions against lower limb IRI from in vitro, in vivo and clinical studies are presented and discussed. These findings may provide mechanistic insights for devising the strategies to improve the clinical outcomes in IRI patients in the near future. Further clinical studies are needed to warrant their use in a clinical setting for lower limb IRI treatment.

Association of Chronic Kidney Disease with perioperative outcomes following acute lower limb revascularization

Background

There is a paucity of data examining the impact of advancing chronic kidney disease stages on outcomes following revascularization for acute limb ischemia. The present study examined the association of chronic kidney disease with in-hospital mortality, amputation, and resource utilization following revascularization for acute limb ischemia using a nationally representative cohort.

Methods

The 2016–2018 National Inpatient Sample was queried to identify all adult hospitalizations with lower extremity acute limb ischemia requiring surgical and/or endovascular interventions. Patients were grouped according to the presence of chronic kidney disease and its severity: no chronic kidney disease, chronic kidney disease 1–3 (chronic kidney disease stages 1 through 3), chronic kidney disease 4–5 (chronic kidney disease stages 4 through 5), and end-stage renal disease. Multivariable logistic and linear models were used to evaluate association of chronic kidney disease stage with outcomes of interest.

Results

Of an estimated 82,610 patients meeting study criteria, 14.8% had chronic kidney disease (chronic kidney disease 1–3: 63.4%, chronic kidney disease 4–5: 12.1%, end-stage renal disease: 24.5%). Compared to those with chronic kidney disease, chronic kidney disease patients were on average older, were more frequently female, and had a higher median Elixhauser Comorbidity Index. Increasing severity of chronic kidney disease was associated with a stepwise increase in unadjusted mortality rates (4.7% in no chronic kidney disease to 12.6% in end-stage renal disease, P < .001). Following risk adjustment, only end-stage renal disease was associated with increased odds of mortality (adjusted odds ratio 3.10, 95% confidence interval 2.28–4.22) and limb amputation (adjusted odds ratio 1.99, 95% confidence interval 1.59–2.48) compared to patients with no chronic kidney disease. Similarly, advancing chronic kidney disease stage conferred increased odds of prolonged length of stay and greater hospitalization costs.

Conclusion

Advanced renal dysfunction demonstrated inferior perioperative outcomes and greater health care expenditures in the study population. These findings imply that quality improvement efforts in acute limb ischemia revascularization should target patients with chronic kidney disease 4–5 and end-stage renal disease.

Thromboembolectomy for acute lower limb ischemia: Contemporary outcomes of two surgical methods from a single tertiary center

OBJECTIVES

The current treatment of acute lower limb ischemia (ALLI) includes open surgical and percutaneous pharmaco-mechanical thromboembolectomy (TE). We hereby report our results with open surgical TE over a 10-year period and compare our outcomes using routine fluoroscopic assisted TE (FATE) with blind and selective on demand fluoroscopic-assisted TE (BSTE).

METHODS

This is a retrospective analysis of all patients who underwent open surgical TE for acute lower limb ischemia at a single tertiary center between 2008 and 2018. Patients were divided into a group who underwent BSTE and another who underwent routine FATE. Data on presentation, medical history, surgery performed, and short-term outcomes were retrieved from medical record. Comparison between baseline characteristics and outcomes of both groups were made using t-test and chi-square analysis.

RESULTS

Over 10 years, 108 patients underwent surgical TE. Thirty-day mortality rate and 30-day major lower extremity amputation rate in the cohort were 12.0% and 6.5%, respectively. On subgroup analysis, 53 patients were treated by BSTE and 55 patients by FATE. There was no significant difference in 30-day mortality rate (11.3% vs 12.7%, p-value = .82) and 30-day major amputation rate (9.4% vs 3.6%, p-value = .454) between the two groups. Local anesthesia was more frequently performed in patients undergoing FATE (58.2% vs 24.5%, p-value < .001). More than one arteriotomy was more frequently required in patients undergoing BSTE (2.6% vs 45.5%, p-value < .001). Patients with infrapopliteal involvement undergoing FATE required less further interventions such as patch angioplasty (2.6% vs 36.4%, p-value < .001) and bypass (2.6% vs 22.7%, p-value = .01).

CONCLUSION

ALLI remains a disease of high morbidity and mortality. Open surgical TE offers an effective approach to treat ALLI. The addition of fluoroscopy to the conduction of TE could be associated with valuable benefits, especially in patients with infra-popliteal involvement. Randomized controlled trials are needed to objectively assess the therapeutic potential of FATE.

Association of Frailty With Treatment Selection and Long-Term Outcomes Among Patients With Chronic Limb-Threatening Ischemia

Background The optimal treatment strategy for patients with chronic limb-threatening ischemia (CLTI) is often unclear. Frailty has emerged as an important factor that can identify patients at greater risk of poor outcomes and guide treatment selection, but few studies have explored its utility among the CLTI population. We examine the association of a health record-based frailty measure with treatment choice and long-term outcomes among patients hospitalized with CLTI. Methods and Results We included patients aged >65 years hospitalized with CLTI in the Medicare Provider Analysis and Review data set between October 1, 2009 and September 30, 2015. The primary exposure was frailty, defined by the Claims-based Frailty Indicator. Baseline frailty status and revascularization choice were examined using logistic regression. Cox proportional hazards regression was used to determine the association between frailty and death or amputation, stratifying by treatment strategy. Of 85 060 patients, 35 484 (42%) were classified as frail. Frail patients had lower likelihood of revascularization (adjusted odds ratio [OR], 0.78; 95% CI, 0.75‒0.82). Among those revascularized, frailty was associated with lower likelihood of surgical versus endovascular treatment (adjusted OR, 0.76; CI, 0.72‒0.81). Frail patients experienced increased risk of amputation or death, regardless of revascularization status (revascularized: adjusted hazard ratio [HR], 1.34; CI, 1.30‒1.38; non-revascularized: adjusted HR, 1.22; CI, 1.17‒1.27). Among those revascularized, frailty was independently associated with amputation or death irrespective of revascularization strategy (surgical: adjusted HR, 1.36; CI, 1.31‒1.42; endovascular: aHR, 1.29; CI, 1.243‒1.35). Conclusions Among patients hospitalized with CLTI, frailty is an important independent predictor of revascularization strategy and longitudinal adverse outcomes.

Balloon-Assisted Endovascular Thrombectomy for Tibial Thromboembolism

We present a novel approach to endovascular thrombectomy using the Penumbra Indigo® Aspiration System with balloon assistance for a thromboembolic occlusion to the tibioperoneal trunk and tibial arteries causing acute limb ischemia. This technique allows for effective suction thrombectomy of distal vessels into a shorter, large-diameter aspiration catheter, thereby overcoming the limitations of the longer but smaller aspiration catheters.

Clinical outcomes of surgical embolectomy versus catheter-directed thrombolysis for acute limb ischemia: a nationwide cohort study

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.

Long-term results of the Japanese multicenter Viabahn trial of heparin bonded endovascular stent grafts for long and complex lesions in the superficial femoral artery

OBJECTIVE

To assess the long-term safety and efficacy of endovascular stent grafting to treat long, complex lesions in the superficial femoral artery (SFA).

METHODS

This prospective, multicenter study at 15 Japanese hospitals assessed heparin bonded stent grafts for treating long SFA lesions in patients with symptomatic peripheral arterial disease. Inclusion criteria were Rutherford category 2-5 symptoms (grade 5 without active infection), ankle-brachial index (ABI) ≤ 0.9, and SFA lesions ≥ 10 cm with ≥ 50% stenosis. The key efficacy and safety outcomes were primary-assisted patency (PAP) and adverse events through 24 months, respectively. Secondary outcomes included primary patency (PP), secondary patency, freedom from target lesion revascularization (fTLR), and VascuQOL scoring.

RESULTS

Of 103 subjects (mean age 74.2 ± 7.0 years; 82.5% male), 100 (97.1%) had intermittent claudication. Average lesion length was 21.8 ± 5.8 cm; 87 lesions (84.5%) were TASC C/D classification (65.7% chronic total occlusions). Ninety-two subjects and 61 subjects were evaluable through 24 months and 60 months, respectively. At 24 months, the Kaplan-Meier-estimated PAP rate was 85.7% (95% CI: 76.3‒91.5%), PP rate was 78.8% (95% CI: 68.8‒85.9%), and secondary patency rate was 92.0% (95% CI: 82.4-96.5%). Mean ABI was 0.64 ± 0.12 at baseline and 0.94 ± 0.19 at 24 months (P<.0001). At 24 months, fTLR was 87.2% (95% CI: 78.9-92.3%), and at 60 months, fTLR was 79.1% (95% CI: 67.9-86.8%). No device or procedure-related life- or limb-threatening critical events or acute limb ischemia cases were observed through 5 years. No stent fractures were detected in annually scheduled follow-up x-rays. Scores from the VascuQOL and Walking Impairment Questionnaire were significantly increased at 1 month through 24 months versus baseline values (P<.0001 for both). One subject was converted to open bypass through 5 years.

CONCLUSIONS

Stent grafting of long and complex SFA lesions in claudicant patients is safe and effective through long-term follow-up, with 79.1% fTLR and no study leg amputation, acute limb ischemia, or stent fractures through 5 years.

Pre-operative Neutrophil to Lymphocyte Ratio is Associated With 30 Day Death or Amputation After Revascularisation for Acute Limb Ischaemia

OBJECTIVE

Inflammation is an early feature of acute limb ischaemia (ALI), hence the potential prognostic significance of inflammatory biomarkers. This study aimed to assess the value of pre-operative inflammatory biomarkers, specifically the neutrophil to lymphocyte ratio (NLR) and the platelet to lymphocyte ratio (PLR), for predicting an adverse outcome after revascularisation for ALI.

METHODS

All patients submitted to lower limb revascularisation for Rutherford IIa or IIb ALI at the authors' institution between 2009 and 2019 were screened retrospectively. Pre-operative NLR and PLR were analysed, along with other known prognostic factors. Primary outcome was the composite endpoint of 30 day death or amputation.

RESULTS

A total of 345 patients were included, 84 of whom suffered the primary outcome (24.3%). The median follow up was 23.1 months (3.1 - 52.2). Higher age (OR 1.05 per year increase, 95% CI 1.01 - 1.09), diabetes (OR 2.63, 95% CI 1.14 - 6.06), Rutherford grade IIb vs. IIa (OR 5.51, 95% CI 2.11 - 14.42), higher NLR (OR 1.28 per unit increase, 95% CI 1.12 - 1.47), and fasciotomy need (OR 3.44, 95% CI 1.14 - 10.34) were independently associated with 30 day death or amputation, whereas pre-operative statin or anticoagulant medication were associated with a risk reduction (OR 0.23, 95% CI 0.53 - 0.96 and OR 0.20, 95% CI 0.05 - 0.84, respectively). PLR did not show an independent effect on this population. Pre-operative NLR presented a good discriminative ability (AUC 0.86, 95% CI 0.82 - 0.90). A cut off NLR level ≥ 5.4 demonstrated a 90.5% sensitivity and 73.6% specificity for 30 day death or amputation. Kaplan-Meier analysis showed that patients with pre-operative NLR ≥ 5.4 had significantly lower 30 day, six month and one year amputation free survival when compared with those with NLR < 5.4 (64.8 ± 4.0%, 44.1 ± 4.1%, and 37.5 ± 4.1% vs. 98.5 ± 0.9%, 91.9 ± 2.0%, and 85.9 ± 2.5%, log rank p < .001).

CONCLUSION

In this study, higher pre-operative NLR was associated with 30 day death or amputation following intervention for Rutherford grade IIa or IIb ALI. NLR potentially stands as a simple, widely available and inexpensive biomarker that can refine decision making and possibly contribute to ALI morbidity and mortality reduction.

Oral Anticoagulant and Antiplatelet Therapy for Peripheral Arterial Disease: A Meta-analysis of Randomized Controlled Trials

Peripheral artery disease (PAD) is a common disease affecting over 200 million people worldwide. PAD is associated with significant limb and cardiovascular morbidity and mortality which is reduced by antiplatelet and antithrombotic therapy. However, the optimal type, dose, and time of antithrombotic therapy is still uncertain.We searched 4 electronic databases from January 1, 1990, to June 1, 2020, for randomized controlled trials of patients who received oral anticoagulant and antiplatelet therapy for PAD. The primary outcome was a composite of acute limb ischemia, major amputation, myocardial infarction, ischemic stroke, death from cardiovascular events, or death from any cause. Secondary outcomes included major bleeding, fatal bleeding, and intracranial hemorrhage events.We identified 3 studies that satisfied inclusion and exclusion criteria. Compared with antiplatelet alone, oral anticoagulant plus antiplatelet therapy improved acute limb ischemia (p < 0.00001), stroke (p = 0.005), and major amputation events (p = 0.11). However, oral anticoagulant plus antiplatelet therapy was not effective for prevention of myocardial infarction (p = 0.23), death from cardiovascular events (p = 0.65), or death from any cause (p = 0.66). Additionally, a significant increase in major bleeding events was demonstrated (p < 0.00001). There was no significant difference in fatal bleeding (p = 0.16) or intracranial hemorrhage events (p = 0.43). This meta-analysis showed that oral anticoagulant plus antiplatelet therapy for PAD may improve acute limb ischemia and major amputation or stroke risk compared with antiplatelet therapy alone, but could increase the risk of major bleeding events. On the other hand, measuring myocardial infarction, death, fatal bleeding, or intracranial hemorrhage risk remains controversial.

Predictive Effect of Frailty on Amputation, Mortality, and Ambulation in Patients Undergoing Revascularization for Acute Limb Ischemia

BACKGROUND

Frailty is a common, age-associated syndrome that has been used to predict postoperative outcomes in vascular surgery. This study examines if standard measures of frailty correlate with postoperative outcomes for patients undergoing revascularization for acute limb ischemia (ALI).

METHODS

A retrospective study was conducted on all adult patients undergoing revascularization for ALI at an academic medical center between January 2016 and June 2019. Frailty was calculated with the 11-factor modified frailty index (mFI-11), derived from the Canadian Study of Health and Aging Frailty Index. Outcomes examined included in-hospital mortality, major amputation, site of discharge, and ambulatory status at follow-up.

RESULTS

Fifty-three ambulatory patients presented with ALI during the study time period, with 13.2% deemed not frail (mFI-11 < 3) and 86.8% deemed frail (mFI-11 ≥ 3). Frailty was significantly correlated with discharge to a skilled nursing facility (P = 0.028) and nonambulation at follow-up (P = 0.002). There was no significant correlation with other outcomes, including mortality and amputation. On multivariate analysis, frailty was the only factor contributing to nonambulation at follow-up (P = 0.012). Endovascular treatment did not mitigate the effects of frailty on discharge site and ambulatory status.

CONCLUSIONS

Frailty is exceedingly common in patients with ALI. Although frailty predicts discharge site and nonambulation at follow-up, it is not associated with amputation or death. Therefore, frail patients should not be denied open or endovascular revascularization for ALI.

Outcome of catheter directed thrombolysis for popliteal or infrapopliteal acute arterial occlusion

Management of acute limb ischemia (ALI) due to occlusions in popliteal and infrapopliteal arteries remains a challenge. Open surgical methods and even the novel percutaneous mechanical thrombectomy devices have not shown satisfactory results in these small arteries. The aim of this prospective study was to assess the safety and efficacy of catheter-directed thrombolysis (CDT) in this type of ALI with distal occlusion. Between April 2017 and June 2019, 22 patients with ALI secondary to popliteal or infrapopliteal occlusion were enrolled in the study. Patients with thrombosis, embolism, and thrombosed bypass graft were included; all belong to category I or IIa of Rutherford's classification. Technical success, limb salvage, complications, and mortality were evaluated at short- and long-term follow-up. Technical success was achieved in 81.8%, while 36.4% of patients needed additional balloon angioplasty, major amputation in 13.6%, minor bleeding in 18.2%, and no major hemorrhage. Limb salvage at 30 days and 1 year was 86.4% and 72.7%, respectively. At 1 year, primary patency was 63.6% and mortality was 9.1%. Catheter directed thrombolysis is a safe and highly effective treatment modality for popliteal or infrapopliteal acute limb ischemia unless contraindicated.

Acute Lower Limb Ischemia-Etiology, Pathology, and Management

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.

Long-Term Outcomes of Acute Limb Ischemia: A Retrospective Analysis of 93 Consecutive Limbs

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.

Limb Salvage After Percutaneous Mechanical Thrombectomy in Patients with Acute Lower Limb Ischemia: A Retrospective Analysis from Two Institutions

BACKGROUND

To evaluate the short-term outcomes of percutaneous mechanical thrombectomy (PMT) in patients with acute lower limb ischemia (ALI) and to analyze the effect of ALI of different etiologies on the limb salvage.

MATERIALS AND METHODS

From January 2015 to December 2017, a retrospective analysis was performed on 112 patients (mean age: 66.5 years; 117 limbs in total; 66 limbs in 61 males) with ALI treated with PMT at 2 vascular institutions. Of the 117 limbs, 44 (41 patients) had acute arterial embolism, 36 (34 patients) had acute arterial thrombosis, and 37 (37 patients) had acute stent (31 limbs in 31 patients) or graft (6 limbs in 6 patients) thrombosis. The primary end point was limb salvage rate, and subgroups were analyzed by etiological factors. The secondary end points included patency rates, major bleeding complications, 30-day mortality, and reintervention rates.

RESULTS

The 30-day mortality rate was 3.6%. The incidence of major bleeding complications was 2.7%. During the follow-up, the limb salvage rates at 1 year and 2 years were 83.8% and 74.7%, respectively. Subgroup analysis showed that the limb salvage rate in patients with acute arterial embolism was 92.9% at 2 years after PMT, which was higher than that in patients with acute arterial thrombosis (73.3%, P = 0.04, hazard ratio [HR]: 3.6, 95% confidence interval [CI]: 1.1-11.7) and acute stent/graft thrombosis (62.5%, P = 0.01, HR: 4.7, 95% CI: 1.5-13.6).

CONCLUSIONS

PMT in patients with ALI is effective in preventing amputations over the 3-year study period with a reasonable safety profile, especially in patients with acute arterial embolism.

Outcomes of Peripheral Vascular Interventions in Select Patients With Lower Extremity Acute Limb Ischemia

Background

Contemporary data on patients presenting with acute limb ischemia (ALI), who are selected for treatment with endovascular peripheral vascular interventions (PVI), are limited. Our study examined outcomes following endovascular PVI in patients with ALI by comparing with patients treated for chronic critical limb ischemia using a regional quality improvement registry.

Methods and Results

Of the 11 035 patients in the Vascular Study Group of New England PVI database (2010–2014), we identified 365 patients treated for lower extremity ALI who were 5:1 frequency matched (by procedure year and arterial segments treated) to 1808 patients treated for critical limb ischemia. ALI patients treated with PVI had high burden of atherosclerotic risk factors and were more likely to have had prior ipsilateral revascularizations. ALI patients were less likely to be treated with self‐expanding stents and more likely to undergo thrombolysis than patients with critical limb ischemia. In multivariable analysis, ALI was associated with higher technical failure (odds ratio 1.7, 95% confidence interval, 1.1%–2.5%), increased rate of distal embolization (odds ratio 2.7, 95% confidence interval, 1.5%–4.9%), longer length of stay (means ratio 1.6, 95% confidence interval, 1.4%–1.8%), and higher in‐hospital mortality (odds ratio 2.8, 95% confidence interval, 1.3%–5.9%). ALI was not associated with risk of major amputation or mortality at 1 year.

Conclusions

In a multicenter cohort of patients treated with PVI, we found that ALI patients selected for treatment with endovascular techniques experienced greater short‐term adverse events but similar long‐term outcomes as their critical limb ischemia counterparts. Further studies are needed to refine the selection of ALI patients who are best served by PVI.

Acute Limb Ischemia Secondary to Native Artery Occlusion: Results of a Contemporary Case Series

BACKGROUND

The treatment of acute limb ischemia (ALI) has barely changed over the last years. However, the progressive implementation of anticoagulants, antiplatelet agents or statins within the population might have modified the profile and prognosis of patients suffering an ALI. The aim of this study was to evaluate the current results of the management of ALI secondary to a native artery occlusion.

METHODS

Retrospective study of 220 consecutive patients (mean age 78 years; 49% male) was conducted between 2007 and 2015. ALI secondary to trauma or grafts/stents occlusions were excluded. Statistical analysis was performed with logistic regression.

RESULTS

A total of 141 cases (64.1%) were attributed to embolism and 79 (35.9%) to acute arterial thrombosis. Peripheral neuro-ischemic impairment occurred in 135 patients (61.4%), being severe in 42 (19.1%). ALI treatment included anticoagulation (n = 27; 12.3%), regional fibrinolysis (n = 2; 1%), embolectomy/thrombectomy (n = 129; 58.6%), angioplasty/stenting (n = 8; 3.6%), bypass (n = 47; 21.3%) or direct major limb amputation (n = 7; 3.2%). Limb salvage and survival rates at 30/90 days were 95%/95% and 82.3%/74.1%, respectively. Independent risk factors for major amputation were diabetes, severe neuro-ischemic impairment, acute arterial thrombosis and treatment delay >1 day after vascular consultation. In addition, age, chronic peripheral arterial disease, any neuro-ischemic impairment and a hospitalization for any other reason simultaneous to the ALI were independently associated with mortality.

CONCLUSIONS

Regardless of excellent limb salvage rates, patients currently suffering from an ALI are, when compared to previous studies, older than before and with an increased rate of mortality. Risk factors do not appear to be modifiable once the ALI appears so prevention strategies should be aimed to avoid the episode.

Current Status of Arterial Revascularization for the Treatment of Critical Limb Ischemia in Infrainguinal Atherosclerotic Disease

Critical limb ischemia (CLI) is the most severe form of peripheral arterial disease (PAD) that may result in limb loss and even death; thus, the fast and proper treatment should be employed as earlier as possible to prevent these catastrophic consequences. Arterial revascularization is almost always an indispensable treatment option for CLI. Although both endovascular and surgical revascularization procedures have an important role, nowadays, the hybrid revascularization as a combination of these revascularization procedures has also gained increasing popularity in the treatment of patients with CLI. This review provides an update on the arterial revascularization strategies for the treatment of CLI.

Catheter-directed thrombolysis is not limited to acute limb ischemia treatment: experience from a division of vascular surgery

BACKGROUND

Thrombolytic treatment has many potential indications in the era of modern vascular surgery. We aimed to analyze the contemporary experience in the catheter-directed, intraarterial thrombolysis in different clinical scenarios.

METHODS

The available data of 121 patients with different types (acute, subacute, complications of vascular procedures) of lower limb ischemia treated by means of the intraarterial, catheter-directed thrombolysis between November 2011 and December 2016 were retrospectively analyzed. The basic treatment protocol, utilized in 92% of patients, was a catheter-directed infusion of 40 mg of alteplase within 3.5 hours. Pre- and intraprocedural factors (indications, demographic details, comorbidities, the dose of alteplase utilized, underlying lesions procedures), as well as postoperative outcomes (lysis grade, death, complications, reinterventions, and limb loss after 1-month observation), were analyzed.

RESULTS

Successful thrombolysis was achieved in 76.1% (92 of 121) patients. The success rate was similar for acute, subacute limb ischemia and thrombotic complications of vascular procedures. Around 67.8% of patients (N.=82) had procedures to correct underlying lesions performed. Overall complication rate was 28.1%, but the major bleeding was observed in only 5% (6 patients). Neither intracranial bleeding nor gastrointestinal bleeding occurred. No mortality, 1.7% reintervention rate and 10.7% amputation rate were recorded during one-month follow-up.

CONCLUSIONS

Accelerated intraarterial thrombolysis is an effective measure in the treatment of acute, sub-acute limb ischemia as well as thromboembolic complications of vascular procedures. It carries a low risk of major bleeding. The location of thrombus in the crural arteries adversely affects the treatment results. Atrial fibrillation increases the risk of amputation while complete thrombus lysis is protective.

Morbidity and mortality after emergency lower extremity embolectomy

OBJECTIVE

Emergency lower extremity embolectomy is a common vascular surgical procedure that has poorly defined outcomes. Our goal was to define the perioperative morbidity for emergency embolectomy and develop a risk prediction model for perioperative mortality.

METHODS

The American College of Surgeons National Surgical Quality Improvement database was queried to identify patients undergoing emergency unilateral and lower extremity embolectomy. Patients with previous critical limb ischemia, bilateral embolectomy, nonemergency indication, and those undergoing concurrent bypass were excluded. Patient characteristics and postoperative morbidity and mortality were analyzed. Multivariate analysis for predictors of mortality was performed, and from this, a risk prediction model was developed to identify preoperative predictors of mortality.

RESULTS

There were 1749 patients (47.9% male) who met the inclusion criteria. The average age was 68.2 ± 14.8 years. Iliofemoral-popliteal embolectomy was performed in 1231 patients (70.4%), popliteal-tibioperoneal embolectomy in 303 (17.3%), and at both levels in 215 (12.3%). Fasciotomies were performed concurrently with embolectomy in 308 patients (17.6%). The 30-day postoperative mortality was 13.9%. Postoperative complications included myocardial infarction or cardiac arrest (4.7%), pulmonary complications (16.0%), and wound complications (8.2%). The rate of return to the operating room ≤30 days was 25.7%. Hospital length of stay was 9.8 ± 11.5 days, and the 30-day readmission rate was 16.3%. A perioperative mortality risk prediction model based on factors identified in multivariate analysis included age >70 years, male gender, functional dependence, history of chronic obstructive pulmonary disease, congestive heart failure, recent myocardial infarction/angina, chronic renal insufficiency, and steroid use. The model showed good discrimination (C = 0.769; 95% confidence interval, 0733-0.806) and calibrated well.

CONCLUSIONS

Emergency lower extremity embolectomy has high morbidity, mortality, and resource utilization. These data provide a benchmark for this complex patient population and may assist in risk stratifying patients, allowing for improved informed consent and goals of care at the time of presentation.

[Endovascular versus conventional vascular surgery--old-fashioned thinking? Part 2: carotid artery stenosis and peripheral arterial occlusive disease]

Endovascular therapy has widely replaced conventional open vascular surgical reconstruction. For this reason, both techniques were widely considered to be competing approaches. Evidence-based data from randomized prospective trials, meta-analyses and clinical registries, however, demonstrated that both techniques should be used to complement each other. It became increasingly more evident that the use of either procedure depends on the underlying disease and the anatomical conditions, whereby a combination of both (hybrid approach) may be the preferred option in certain situations. This review focuses on the treatment of patients with carotid artery stenosis, intermittent claudication, critical limb ischemia and acute limb ischemia.