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Fierro AL, Abeshouse M, Lagziel T, Lantis JC. Arterial Leg Ulcers in the Octogenarian. Clin Geriatr Med 2024; 40:397-411. [PMID: 38960533 DOI: 10.1016/j.cger.2023.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024]
Abstract
Arterial leg ulcers are a debilitating sequela of chronic ischemia, and their management, particularly in the octogenarian, is an immense challenge. ALUs are frequently a manifestation of end-stage peripheral arterial disease, and their presence portends a high morbidity and mortality. Management primarily relies on restoration of flow, but in the geriatric population, interventions may carry undue risk and pathologies may not be amenable. Adjunctive therapies that improve quality of life and decrease morbidity and mortality are therefore essential, and understanding their benefits and limitations is crucial in developing a multimodal treatment algorithm of care for the uniquely challenging octogenarian population.
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Affiliation(s)
- Allegra L Fierro
- Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA.
| | - Marnie Abeshouse
- Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - Tomer Lagziel
- Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA
| | - John C Lantis
- Department of Surgery, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029, USA; Department of Surgery, Mount Sinai West, 425 West 59th Street, 7th Floor, New York, NY 10019, USA
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Miah MMR, Avabde D, Ghahramani I, Hemanth R, Abbas R, Maha Q, Beech A, Salem M. Graft Failure After Revascularization for Chronic Limb-Threatening Ischaemia (CLTI) Patients: The Role of Graft Surveillance. Cureus 2024; 16:e53036. [PMID: 38410345 PMCID: PMC10895559 DOI: 10.7759/cureus.53036] [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] [Accepted: 01/26/2024] [Indexed: 02/28/2024] Open
Abstract
Introduction Failure of infrainguinal bypass grafts remains a major problem tackled by vascular surgeons despite a meticulous surgical technique. All infrainguinal bypasses should go under routine surveillance to pick the grafts at risk for the prevention of graft failure. Objectives The aim was to find out if we were adhering to the European Society of Vascular Surgery (ESVS) guidelines in the management of chronic limb-threatening ischaemia (CLTI) patients, including postoperative follow-up and to monitor whether the patients were having postoperative duplex surveillance scans to pick any graft at risk. Methods All patients who underwent infra-inguinal bypass procedures for CLTI during the last eight months (from mid-January to mid-September 2023) in our vascular unit were included. Retrospective data were collected. Results A total of 38 patients had lower limb bypass procedures over the last eight months (from 15 January till 14 September 2023). However, two femoral-femoral (fem-fem) crossovers, one Ilio-popliteal, and one pedal bypass were excluded. Thus, a total of 36 patients were included in the study (n=34). The vast majority (n=27, 79.4%) had femoro popliteal bypass anastomosing distally to above knee (AK) or below knee (BK) popliteal artery, and the rest (n=7, 20.5%) had distal bypass (fem-distal or pop-distal bypass). Moreover, 18% of patients had amputation, 15% of patients died, and 61% of the remaining patients were on surveillance. Of those, who were not on surveillance, 44% of them had graft occlusion. Conclusion Surveillance can predict graft at risk, and the graft occlusion can be prevented by appropriate intervention. Every vascular unit should have its own post-procedural follow-up strategies.
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Affiliation(s)
| | - Dani Avabde
- Vascular Surgery, Nottingham University Hospitals NHS Trust, Nottingham, GBR
| | | | - Raehan Hemanth
- Surgery, Nottingham University Hospitals NHS Trust, Nottingham, GBR
| | - Ridda Abbas
- Vascular Surgery, Nottingham University Hospitals NHS Trust, Nottingham, GBR
| | - Quratulain Maha
- Vascular Surgery, Nottingham University Hospitals NHS Trust, Nottingham, GBR
| | - Andrew Beech
- Vascular Surgery, Nottingham University Hospitals NHS Trust, Nottingham, GBR
| | - Murtaza Salem
- Vascular Surgery, Nottingham University Hospitals NHS Trust, Nottingham, GBR
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Balasundaram N, Thaghalli Sunil Kumar V, Kanake S, Chandra I, Hamai C, Vogel TR. Performance of the Emergency Surgery Score (ESS) for nonelective infrainguinal open revascularization procedures (NEIOR). Surgery 2023; 173:830-836. [PMID: 36333249 DOI: 10.1016/j.surg.2022.07.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/29/2022] [Accepted: 07/30/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND The Emergency Surgery Score has been previously validated as a reliable; tool to predict postoperative outcomes in emergency general surgery. The purpose of this study was to assess the performance of the Emergency Surgery Score for infrainguinal open revascularization procedures in the nonelective setting. METHODS The American College of Surgeons' National Surgical Quality Improvement Program database was retrospectively analyzed for patients undergoing infrainguinal open revascularization procedures in the nonelective setting between 2015 and 2019. The performance of the Emergency Surgery Score in predicting mortality in each procedure was assessed using receiver operating characteristic analyses. RESULTS A total of 5,027 patients underwent infrainguinal open revascularization procedures in the nonelective setting with median age 68 (±11.66 standard deviation), with 1,666 females (33.1%). The 30-day mortality rate was 2.7%. The Emergency Surgery Score correlated with 30-day mortality (area under the curve was 0.738). The Emergency Surgery Score also predicted risk of death/discharge to hospice (area under the curve 0.756), discharge to rehab (area under the curve 0.643), renal failure (area under the curve 0.741), postintervention ventilation requirement (0.684), stroke (0.717), cardiopulmonary arrest (0.657), and septic shock (0.697). A cumulative frequency table of mortality with Emergency Surgery Score was used to partition patients into quartiles of Emergency Surgery Score ≤5, Emergency Surgery Score of 6, Emergency Surgery Score of 7 or 8, and Emergency Surgery Score ≥9. A Cochran-Armitage test showed linear trend toward increased 30-day mortality among the quartiles with increasing Emergency Surgery Score (P < .001), with quartile 4 (Emergency Surgery Score ≥10) having 13 times odds of increased 30-day mortality compared to reference quartile 1 (Emergency Surgery Score ≤4). CONCLUSION Emergency Surgery Score performance accurately predicts mortality for infrainguinal open revascularization procedures in the nonelective setting procedures. It may be useful for preoperative risk stratification and for national benchmarking after nonelective open lower extremity procedures.
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Affiliation(s)
| | | | - Shubham Kanake
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Isaiah Chandra
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Callie Hamai
- Division of Vascular Surgery, University of Missouri, Columbia, MO
| | - Todd R Vogel
- Division of Vascular Surgery, University of Missouri, Columbia, MO
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Gunawardena M, Salami M, Howard A, Awupetu A. Does the Mode of Anaesthesia (General or Regional) Affect Survival and Complications Following Femoropopliteal and Femorodistal Bypass? Cureus 2022; 14:e32104. [DOI: 10.7759/cureus.32104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2022] [Indexed: 12/04/2022] Open
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Kulkarni R, Andraska E, McEnaney R. Structural Remodeling of the Extracellular Matrix in Arteriogenesis: A Review. Front Cardiovasc Med 2021; 8:761007. [PMID: 34805316 PMCID: PMC8602576 DOI: 10.3389/fcvm.2021.761007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/11/2021] [Indexed: 01/10/2023] Open
Abstract
Lower extremity arterial occlusive disease (AOD) results in significant morbidity and mortality for the population, with up to 10% of patients ultimately requiring amputation. An alternative method for non-surgical revascularization which is yet to be fully understood is the optimization of the body's own natural collateral arterial network in a process known as arteriogenesis. Under conditions of conductance vessel stenosis or occlusion resulting in increased flow, shear forces, and pressure gradients within collaterals, positive remodeling occurs to increase the diameter and capacity of these vessels. The creation of a distal arteriovenous fistula (AVF) will drive increased arteriogenesis as compared to collateral formation with the occlusion of a conductance vessel alone by further increasing flow through these arterioles, demonstrating the capacity for arteriogenesis to form larger, more efficient collaterals beyond what is spontaneously achieved after arterial occlusion. Arteries rely on an extracellular matrix (ECM) composed of elastic fibers and collagens that provide stability under hemodynamic stress, and ECM remodeling is necessary to allow for increased diameter and flow conductance in mature arterial structures. When positive remodeling occurs, digestion of lamella and the internal elastic lamina (IEL) by matrix metalloproteinases (MMPs) and other elastases results in the rearrangement and thinning of elastic structures and may be replaced with disordered elastin synthesis without recovery of elastic function. This results in transmission of wall strain to collagen and potential for aneurysmal degeneration along collateral networks, as is seen in the pancreaticoduodenal artery (PDA) after celiac occlusion and inferior mesenteric artery (IMA) with concurrent celiac and superior mesenteric artery (SMA) occlusions. Further understanding into the development of collaterals is required to both better understand aneurysmal degeneration and optimize collateral formation in AOD.
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Affiliation(s)
- Rohan Kulkarni
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Elizabeth Andraska
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Ryan McEnaney
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
- Veterans Affairs Hospitals Pittsburgh Healthcare System, Pittsburgh, PA, United States
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Singh N, Patel R, Hingorani A, Ascher E. Case report of superficial femoral artery and popliteal artery aneurysm repair using brachial vein. Vascular 2021; 30:599-602. [PMID: 34056975 DOI: 10.1177/17085381211019588] [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: 11/15/2022]
Abstract
BACKGROUND Several veins have been well-recognized as acceptable conduits for infrainguinal bypass surgery when the ipsilateral greater saphenous vein is unavailable. However, there is a paucity of literature describing the brachial vein as an adequate alternative. In the absence of other viable autogenous conduits, we describe the use of a brachial vein as a successful alternative for lower extremity revascularization. METHODS A 70-year-old man presented with a chief complaint of right calf pain. Duplex ultrasound imaging of his right lower extremity revealed right-sided 2.5 cm acutely thrombosed superficial femoral artery and popliteal artery aneurysms. The patient underwent a suction thrombectomy with tissue plasminogen activator using the Power Pulse feature and Solent catheter from the AngioJet® (Boston-Scientific, Marlborough, MA) system. To repair the thrombosed aneurysms, an open bypass was planned. Due to lack of viable alternative traditionally used venous conduits, a bypass was created using the patient's brachial vein. RESULTS A bypass was created from the superficial femoral artery to the P2 segment of the popliteal artery using a non-reversed brachial vein with ligation of the side branches of the superficial femoral artery and popliteal artery aneurysm from within the sac lumen. Completion angiogram revealed runoff through the anterior tibial artery only. Follow-up imaging at three months demonstrated a patent brachial bypass. CONCLUSION Brachial veins can be safely used as viable venous conduits for lower extremity bypass surgery and should therefore be considered as an alternative when more commonly used veins are unsuitable or unavailable. However, more research is needed to determine the potential opportunities and challenges this alternative may present.
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Affiliation(s)
- Nikita Singh
- Vascular Institute of New York, Brooklyn, NY, USA
| | - Ronak Patel
- Vascular Institute of New York, Brooklyn, NY, USA
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Mirza AJ, Mohammed NA, Taha AY, Mahwi TO, Mahmood NN. Below-the-Knee Intervention for Ischemic Diabetic Foot in Kurdistan, Iraq: A Case-Control Study. Ann Vasc Surg 2020; 72:535-543. [PMID: 32927043 DOI: 10.1016/j.avsg.2020.08.141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/18/2020] [Accepted: 08/23/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Management of the ischemic diabetic foot (DF) due to infrapopliteal arterial disease is challenging and controversial. Observation, bypass surgery, and endovascular intervention are the 3 available options. Outcome of percutaneous transluminal angioplasty (PTA) versus conservative therapy is evaluated in this prospective study from Sulaymaniyah, Iraq. METHODS Over 2 years starting at January 2018, 40 patients with ischemic DF underwent PTA and compared with a control group (n = 78) of ischemic DF managed conservatively. Besides clinical assessment, all patients underwent Doppler ultrasonography and computed tomography angiography while conventional angiography was reserved for PTA group. Patients who fulfilled the standard angiographic findings underwent standard PTA, and their outcome was compared with the control group. RESULTS Mean age was 64 years; 70% (n = 28) were men with a male: female ratio of 2.3: 1. Renal function was impaired in (n = 11, 27.5%), and 7 (17.5%) patients were smokers. The commonest clinical presentation was nonhealing ulcers (n = 39, 97.5%), and most patients (n = 39, 97.5%) had Fontaine IV and Rutherford V-VI grades. Most lesions were anatomically complex; Trans-Atlantic Inter-Society Consensus C and D types, Graziani class ≥4 (75%), long segment (n = 28, 70%), and chronic total occlusion (n = 26, 65%). Success rate was (n = 38, 95%), and no patient died. Ulcer healing was higher (67.5% vs. 34.6%), and ulcer recurrence was lower (20% vs. 47.4%) in PTA group but amputation rate was not significantly different (12.5% vs. 12.8%) (P < 0.05). CONCLUSIONS Although amputation and death rates were not significantly different, endovascular intervention achieved better ulcer healing in ischemic DF compared with the conservative approach.
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Affiliation(s)
- Aram Jamal Mirza
- Department of Interventional Cardiology, Slemani Cardiac Hospital, Sulaymaniyah, Iraq
| | - Naser Abdullah Mohammed
- Department of Radiology, Sulaymaniyah Teaching Hospital, Sulaymaniyah, Iraq; Unit of Radiology, Department of Surgery, College of Medicine, University of Sulaimani, Sulaymaniyah, Iraq
| | - Abdulsalam Yaseen Taha
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, University of Sulaimani, Sulaymaniyah, Iraq.
| | - Taha Othman Mahwi
- Department of Internal Medicine (Endocrinology), College of Medicine, University of Sulaimani, Sulaymaniyah, Iraq
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Almorza C, Marcos L, Diaz C, Galarza A, Casajuana E, Mateos E, Clara A. Influence of Operative Time in the Results of Infrainguinal Bypass for Chronic Limb Threatening Ischemia. World J Surg 2020; 44:4261-4266. [PMID: 32783123 DOI: 10.1007/s00268-020-05726-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND An increased operative time (OT) has been associated with a higher rate of adverse outcomes after several surgical procedures although scarce evidence exists for infrainguinal bypass surgery (IBS) and its impact beyond the postoperative period. The aim of this study was to define surgical characteristics related to a prolonged OT in IBS for chronic limb threatening ischemia and its influence on postoperative and 1-year outcomes. MATERIALS AND METHODS Retrospective study of 249 consecutive patients (mean age 72.4 years, 73.1% male) undergoing IBS for CLI between 2008 and 2018. The characteristics related to the duration of surgery and its impact on outcome were assessed with a multiple linear regression and a multivariate logistic regression, respectively. RESULTS Interventions associated with a prolonged OT included the bypass to a below-the-knee artery (additional 36 min, p = 0.002), the need for an alternative vein or a hybrid PTFE-vein graft (additional 37 min, p = 0.02) and inflow associated procedures (additional 47 min, p < 0.001). OT was associated with a higher rate of postoperative complications (OR for each additional 30 min 1.123, 95% CI 1.021-1.234) and need for a sociosanitary facility at discharge (OR 1.143, 95% CI 1.033-1.265). At 1-year of follow-up, OT was related to a higher major amputation rate (OR 1.201, 95% CI 1.036-1.393) and non-significantly to mortality (OR 1.125, 95% CI 0.999-1.268). CONCLUSIONS A prolonged OT is a risk factor for adverse outcomes after IBS that extends beyond the immediate postoperative period. Further research is needed to evaluate how an expected high OT might influence decision-making.
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Affiliation(s)
- Cristina Almorza
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain
| | - Lidia Marcos
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain.,Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Carles Diaz
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain
| | - Andrés Galarza
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain
| | - Eduard Casajuana
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain
| | - Eduard Mateos
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain
| | - Albert Clara
- Department of Vascular Surgery, Hospital del Mar, Paseo Marítimo 25-29, 08003, Barcelona, Spain. .,Universitat Autónoma de Barcelona, Barcelona, Spain. .,CIBER Cardiovascular, Barcelona, Spain.
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Kehagias E, Ioannou CV, Bouloukaki I, Papadaki E, Galanakis N, Kontopodis N, Tsetis D. Feasibility of ischemic leg ulcer healing using percutaneous techniques: a real-life study. Acta Radiol 2020; 61:353-360. [PMID: 31319687 DOI: 10.1177/0284185119862955] [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: 01/22/2023]
Abstract
Background Percutaneous transluminal angioplasty is established as the first-line vascular procedure in patients with lower extremity artery disease. Purpose We aimed to evaluate the technical and clinical effectiveness of percutaneous transluminal angioplasty in the management of ischemic foot ulcers. Material and Methods All consecutive patients presenting with a foot ulcer at the outpatient vascular surgery clinic of our hospital between June 2009 and June 2015 were evaluated using foot pulse assessment, ankle-brachial index, and duplex scanning. If non-invasive parameters suggested lower extremity artery disease, CT angiography and/or digital subtraction angiography were performed and a percutaneous transluminal angioplasty was carried out when feasible during the same session. All patients were followed until healing, amputation, death, or for at least two years. Short- and long-term clinical success was evaluated based on ulcer size and appearance. Patients with worsening ulcers after percutaneous transluminal angioplasty underwent bypass grafting or amputation. Results Percutaneous transluminal angioplasty was performed in 161 patients (100%) with stenoses > 50%, including cases lesions > 10 cm and/or multiple/calcified lesions, 144 of which completed the study. In 88 (61.2%) patients, percutaneous transluminal angioplasty was performed in the suprapopliteal axis exclusively, in 10 (6.8%) patients in the infrapopliteal axis only, and in 46 (31.9%) in both levels. Percutaneous transluminal angioplasty was technically successful in 141 (98%) patients. After 3.1 years, the rate of healing was 68%, limb salvage 88%, overall survival 69.5%, and amputation-free survival 64%. Conclusion Our data suggest that percutaneous transluminal angioplasty for ischemic foot ulceration treatment is in the majority of patients feasible, effective, and safe with high rates of healing and limb salvage.
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Affiliation(s)
- Elias Kehagias
- Interventional Radiology Unit, Department of Radiology, University of Crete Medical School, Heraklion, Crete, Greece
| | - Christos V Ioannou
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University of Crete Medical School, Heraklion, Crete, Greece
| | - Izolde Bouloukaki
- Interventional Radiology Unit, Department of Radiology, University of Crete Medical School, Heraklion, Crete, Greece
| | - Evangelia Papadaki
- Interventional Radiology Unit, Department of Radiology, University of Crete Medical School, Heraklion, Crete, Greece
| | - Nikolaos Galanakis
- Interventional Radiology Unit, Department of Radiology, University of Crete Medical School, Heraklion, Crete, Greece
| | - Nikolaos Kontopodis
- Vascular Surgery Unit, Department of Cardiothoracic and Vascular Surgery, University of Crete Medical School, Heraklion, Crete, Greece
| | - Dimitrios Tsetis
- Interventional Radiology Unit, Department of Radiology, University of Crete Medical School, Heraklion, Crete, Greece
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Baram A, Baban ZT. Short and long-term outcomes of the peripheral arterial indirect bypass in diabetic patients with chronic limb-threatening ischemia: Single-center case series. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Baram A, Abdullah TN, Taha AY. Femoropopliteal bypass for chronic lower limb ischemia: A prospective cohort study and single center cases series. INTERNATIONAL JOURNAL OF SURGERY OPEN 2019. [DOI: 10.1016/j.ijso.2019.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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