Contrast-Associated Acute Kidney Injury in Patients with and without Diabetes Mellitus Undergoing Computed Tomography Angiography and Local Thrombolysis for Acute Lower Limb Ischemia

Therapeutic management and amputation options in a long time delayed blunt popliteal artery injury

PURPOSE

To report the experience of treatment on blunt traumatic popliteal artery injury (PAI) combined orthopedic injuries and determine the amputation-associated factors.

METHODS

From January 2008 to December 2019, 55 patients in level I trauma center with traumatic blunt PAI were retrospectively reviewed. Variables were retrospectively collected and statistically analyzed. Patients with PAI with limb selvage, primary amputation, and secondary amputation were retrospectively grouped and compared.

RESULTS

A total of 55 patients with a median age of 41.4 years (range 18-70), of which 45 were males (81.8%) and 10 were females (18.2%), were enrolled. The overall amputation rate was 36.4% because 88.6% of patients faced more than 6 h of delay before treatment. The average injury severe score (ISS) and abbreviated injury score (AIS) were 10.4 (range 9-34) and 8.2 (range 5-16), respectively. Multivariate regression analysis showed that the number of hospitalization days was a significantly related factor to amputation. After a median follow-up of 56 months (range 12-132), no death, another limb loss, or claudication was found in all patients.

CONCLUSIONS

Patients with PAI are commonly accompanied by multiple injuries that increase the risk of amputation; therefore, timely treatments are urgently required. Reducing the severity of ischemia by fasciotomy, not losing time by performing preoperative imaging or diagnostic tests, and repairing the associated venous injury can help to optimize the rates of limb salvage. However, impact factors, such as the gender and age of the patient, injured mechanisms, concomitant injuries, AIS, ISS, and surgical times, are not associated with the outcomes of amputation. Nonetheless, endeavors to salvage the limbs as far as possible should be made.

Short-term complications and outcomes in pharmaco-mechanical thrombolysis first and catheter-directed thrombolysis first in patients with acute lower limb ischemia

BACKGROUND

Pharmaco-mechanical thrombolysis (PMT) has emerged as a treatment option in patients with acute lower limb ischemia (ALI), especially Rutherford IIb (motor deficit) for rapid revascularization, but supportive data is scarce. The aim of the present study was to compare effect of thrombolysis, complications, and outcomes of PMT first versus catheter-directed thrombolysis (CDT) first in a large cohort of patients with ALI.

BASIC PROCEDURES

All endovascular thrombolytic/thrombectomy events in patients with ALI performed between January 1^st 2009 and December 31^st 2018 (n=347) were included. Successful thrombolysis/thrombectomy was defined as complete or partial lysis. Reasons for use of PMT was described. Complications such as major bleeding, distal embolization, and new onset of renal impairment, and major amputation and mortality at 30 days were compared between PMT (AngioJet™) first and CDT first groups in a multi-variable logistic regression model with adjustment for age, gender, atrial fibrillation, and Rutherford IIb.

MAIN FINDINGS

The most common reason for initial use of PMT was need of rapid revascularization, and the most common reason for use of PMT after CDT was insufficient effect of CDT. Presentation of Rutherford IIb ALI was more common in the PMT first group (36.2% vs 22.5%, respectively, p=0.027). Among 58 patients receiving PMT first, 36 (62.1%) were terminated within a single session of therapy without need of CDT. The median duration of thrombolysis was shorter (p<0.001) for the PMT first group (n=58) compared to the CDT first (n=289) group (4.0 hours vs 23.0 hours, respectively). There was no significant difference in amount of tissue plasminogen activator given, successful thrombolysis/thrombectomy (86.2% and 84.8%), major bleeding (15.5% and 18.7%), distal embolization (25.9% and 16.6%), major amputation or mortality at 30-day (13.8% and 7.7%) in the PMT first compared to the CDT first group, respectively. The proportion of new onset of renal impairment was higher in the PMT first compared to the CDT first group (10.3% versus 3.8%, respectively), and the increased odds (Odds ratio 3.57, 95% CI 1.22 - 10.41) was maintained in the adjusted model. In Rutherford IIb ALI, no difference in rate of successful thrombolysis/thrombectomy (76.2% and 73.8%), complications or 30-day outcomes was found between PMT first (n=21) and CDT (n=65) first group.

CONCLUSION

PMT first appears to be a good treatment alternative to CDT first in patients with ALI, including Rutherford IIb. The found renal function deterioration in the PMT first group needs to be evaluated in a prospective, preferably, randomized trial.

Prophylactic and Therapeutic Fasciotomy for Acute Compartment Syndrome after Revascularization for Acute Lower Limb Ischemia - Renal and Wound Outcomes

OBJECTIVES

Acute Compartment Syndrome (ACS) is a significant complication after revascularization for Acute Lower Limb Ischemia (ALI). High risk patients sometimes undergo prophylactic fasciotomy (PF) to prevent ACS. Patients that develop ACS undergo therapeutic fasciotomy (TF). The optimal timing of fasciotomy has been debated. The aim of this study was to describe and compare renal and wound outcomes in patients undergoing PF and TF.

METHODS

A retrospective cohort study including 76 patients undergoing PF (n=40) or TF (n=36) after revascularization for ALI between 2006 and 2018. Estimated Glomerular Filtration Rate (e-GFR) was used to evaluate renal function and compare within (paired-samples t-test) and between (ANOVA) groups. Wound complications and healing time were compiled from the complete wound healing period and compared between groups with Pearson's chi²- and log-rank test, respectively.

RESULTS

E-GFR improved over the in-hospital period with 8.2ml/min/1.73m² (95% CI 2.4-14.1, p=0.007) in the PF group and 4.4ml/min/1.73m² (95% CI 1.2-7.7, p=0.010) in the TF group, with no significant difference between the two groups (0.3ml/min/1.73m², 95% CI -6.7-7.4, p=0.93). The rate of wound infections was higher after TF (PF=60.6 % and TF=82.4 %, p=0.048), whereas rate of other wound complications (PF=61.3 % and TF=35.3%, p=0.036) was higher after PF.

CONCLUSION

Overall wound complications were high, whereas renal function improved during in-hospital stay. A more conservative approach to fasciotomy could avoid unnecessary fasciotomies and reduce wound complications, while have the potential to sufficiently preserve renal function if fasciotomy is needed for ACS. This would be possible and safe if an early diagnosis and treatment of ACS can be ensured.