Avoiding peripheral nerve injury in arterial interventions

Advances in Exosome-Based Therapies for the Repair of Peripheral Nerve Injuries

Peripheral nerve injuries (PNIs) are the term used to describe injuries that occur to the nerve fibers of the peripheral nervous system (PNS). Such injuries may be caused by trauma, infection, or aberrant immunological response. Although the peripheral nervous system has a limited capacity for self-repair, in cases of severe damage, this process is either interrupted entirely or is only partially completed. The evaluation of variables that promote the repair of peripheral nerves has consistently been a focal point. Exosomes are a subtype of extracellular vesicles that originate from cellular sources and possess abundant proteins, lipids, and nucleic acids, play a critical role in facilitating intercellular communication. Due to their modifiable composition, they possess exceptional capabilities as carriers for therapeutic compounds, including but not limited to mRNAs or microRNAs. Exosome-based therapies have gained significant attention in the treatment of several nervous system diseases due to their advantageous properties, such as low toxicity, high stability, and limited immune system activation. The objective of this review article is to provide an overview of exosome-based treatments that have been developed in recent years for a range of PNIs, including nerve trauma, diabetic neuropathy, amyotrophic lateral sclerosis (ALS), glaucoma, and Guillain-Barre syndrome (GBS). It was concluded that exosomes could provide favorable results in the improvement of peripheral PNIs by facilitating the transfer of regenerative factors. The development of bioengineered exosome therapy for PNIs should be given more attention to enhance the efficacy of exosome treatment for PNIs.

Electrophysiological Assessment of Paresthesia in Patients Following Radial Angiography: A Prospective Study

BACKGROUND

Radial angiography, preferred for its safety and comfort in percutaneous coronary interventions, occasionally leads to paresthesia-a tingling or numbing sensation in the hand. This study aimed to investigate the presence of nerve damage in patients experiencing paresthesia post-radial angiography through electrophysiological examination.

METHODS

This prospective study involved 77 patients who developed hand paresthesia following radial angiography. Excluded were those with malignancy, pregnancy, pace-makers, or recent angiography. Nerve conduction studies were performed using the Neuropack MEB 9102K EMG device, assessing sensory and motor amplitudes, latencies, and velocities of median, ulnar, and radial nerves.

RESULTS

The study included 77 patients (23 females, 54 males; average age 58.39 ± 10.44 years). In 11 diabetic patients, polyneuropathy was detected. For the remaining 66 patients, electrophysiological evaluations showed no significant pathological findings. Comparative analysis of both upper extremities revealed no significant differences in nerve conduction parameters between the side where angiography was performed and the other side. Despite paresthesia complaints, no electrophysiological evidence of nerve damage was found, suggesting that symptoms might be due to local irritation rather than direct nerve injury. This aligns with the safety profile of radial angiography and underscores the importance of distinguishing between transient paresthesia and serious nerve complications.

CONCLUSION

Paresthesia post-radial angiography, while clinically notable, is not typically associated with nerve damage. This study is significant as it is the first in the literature to demonstrate that radial angiography does not cause nerve damage.

Comparative Analysis of Transpedal and Transfemoral Access During Genicular Artery Embolization for Knee Osteoarthritis

PURPOSE

This retrospective study aimed to compare the efficacy and safety of transpedal access (TPA) with transfemoral access (TFA) in Genicular Artery Embolization (GAE).

MATERIALS AND METHODS

60 patients who underwent GAE between January and June 2023, were recruited and outcomes were compared between the TFA (n = 37) and TPA (n = 23) groups. Technical and clinical success rates, complications, and patient-reported outcomes were assessed.

RESULTS

All patients attained a 100% technical success rate, which was defined as the successful selective catheterization and embolization of at least one feeding artery to the knee joint, without encountering any major complications. Minor complications, observed in 12/60 patients (20%), were predominantly manifested as a transient skin discoloration. The TPA group had a comparatively higher (p = 0.008) rate of minor complication than the TFA group. Notably, TPA was associated with a longer duration of the procedure (p = 0.013), duration of fluoroscopy (p = 0.004), increased total air kerma (p = 0.037), dose-area product values (p = 0.021), and a greater incidence of vasospasm (p = 0.018) than TFA. However, TPA patients reported shorter recovery times and less post-procedural discomfort, especially reduced back pain due to postinterventional bedrest (p < 0.001). At the 3-month follow-up, the clinical success rate was similar between the two groups (p = 0.905).

CONCLUSION

TFA is the safer and faster method for GAE, offering fewer complications and reduced radiation exposure. For patients with challenging groin anatomies, however, TPA may provide a valuable alternative.

A Case Report of Neuropathic Pain and Unilateral Lower Extremity Weakness Following a Cardiac Arrest

Femoral nerve palsy is a rare, but significant complication following percutaneous coronary intervention (PCI) for conditions such as myocardial infarction. We present a case of a 61-year-old male patient who presented for cardiac rehabilitation following an emergent PCI procedure for cardiac arrest secondary to ST-elevation myocardial infarction. He later developed right lower extremity weakness and severe neuropathic pain on arrival to the acute rehabilitation unit. After physical examination and electrodiagnostic studies, he was determined to have a right femoral nerve neuropathy. This case report highlights the clinical course, physical examination/electrodiagnostic findings, and subsequent pain management of femoral nerve palsies.

Post-Operative Ischemia and Surgical Technique Affect Late Mortality of Femoral Artery Pseudoaneurysms Following Injection Drug Use

BACKGROUND

Surgical management of infected common femoral artery (CFA) pseudoaneurysms arising from intravenous drug use (IVDU) is clinically challenging with excellent perioperative outcomes reported for a number of techniques. Long-term outcomes after arterial ligation versus revascularization are not known. We report both short- and long-term comparison of lower extremity perfusion and outcomes for 25 patients that underwent simple or more extensive ligation or revascularization treatment.

METHODS

A retrospective analysis of 25 consecutive patients presenting primarily with infected CFA pseudoaneurysms related to IVDU at one referral institution was performed to determine short- and long-term outcomes at time of discharge, 30 days, and 1 year, including intraoperative differences, postoperative and follow-up ankle-brachial index, bacteriology, and postoperative mortality. In addition to a direct comparison between the revascularization patients (n = 12) and simple ligation patients (n = 13), a comparison within the simple ligation group was performed between those who underwent a ligation of the CFA with preservation of the femoral bifurcation (double ligation) and those who underwent ligation of the CFA, superficial femoral artery, and profunda femoral artery individually (triple ligation [TL]).

RESULTS

All techniques resulted in similar mortality at 30 days. Lower extremity perfusion at discharge was highest in the revascularization group, and lowest in the TL patients. One year mortality was significantly higher in the TL cohort.

CONCLUSIONS

This is the first report of long-term outcomes after surgery for infected CFA pseudoaneurysms, and demonstrates increased late mortality in patients treated with extensive (triple) ligation with persistent ischemia. We conclude that revascularization after resection of infected CFA aneurysms, or surgical techniques that preserve or recreate the femoral artery bifurcation cause less ischemia and late mortality in these challenging patients.

Complications of Peripheral Arterial Access in Preterm and Term Neonates: A Systematic Review

The aim of the study is to provide a comprehensive review of vascular complications secondary to peripheral arterial catheterization in preterm and term neonates. The systematic review consisted of searching PubMed, Scopus, Google Scholar, Cochrane Database of Systematic Reviews, and references of journals using pre-trialed MeSH terms and articles. Eight studies were included for full text analysis from 2,369 initial articles: six retrospective reviews and two prospective studies. Rate of complication was 8.6% and all complications were ischemic in nature. Complications most often occurred in neonates with pulmonary/cardiac comorbidities and lower gestational ages. No association was found for weight and sex of neonates. The radial artery site presented with lower rates of complication of 6% and the femoral presented with the highest (16%). Complications predominately occurred in catheter sizes larger than 22 gauge and most often within 1 day of insertion. A low rate of complications (7.4%) was observed in studies that used heparinized saline at the time of catheterization. This study demonstrates an increasing overall rate of complications with ischemia presenting as the most common complication. There seems to be an association between gestational age, comorbidities, site of catheter, size of catheter, and duration of catheter with such complications. This study also demonstrates the association between the use of heparinized saline and a reduction in rate of complications. The authors advocate for a national data collection tool of all pediatric arterial catheters and its complications to be able to analyze and work on best practice to minimize life changing iatrogenic complications.

Upper Extremity Function following Transradial Percutaneous Coronary Intervention: Results of the ARCUS Trial

Objectives. To determine the incidence of upper extremity dysfunction (UED), after a transradial percutaneous coronary intervention (TR-PCI). Background. Transradial approach (TRA) is the preferred approach for coronary interventions. However, upper extremity complications may be underreported. Methods. The ARCUS was designed as a prospective cohort study, including 502 consecutive patients admitted for PCI. Patients treated with transfemoral PCI (TF-PCI) acted as a control group. A composite score of physical examinations and questionnaires was used for determining UED. Clinical outcomes were monitored during six months of follow-up, with its primary endpoint at two weeks. Results. A total of 440 TR-PCI and 62 control patients were included. Complete case analysis (n = 330) at 2 weeks of follow-up showed that UED in the TR-PCI group was significantly higher than that in the TF-PCI group: 32.7% versus 13.9%, respectively ( $p=0.04$ ). The three impaired variables most contributing to UED were impaired elbow extension, wrist flexion, and extension. Multivariate logistic regression showed that smokers were almost three times more likely to develop UED. Conclusions. This study demonstrates that UED seems to occur two times more in TR-PCI than in TF-PCI at 2 weeks of follow-up. However, no significant long-term difference or difference between the intervention arm and the contralateral arm was found at all timepoints.

Multicenter Experience of Upper Extremity Access in Complex Endovascular Aortic Aneurysm Repair

PURPOSE

Upper extremity access (UEA) for antegrade cannulation of aortic side branches is a relevant part of endovascular treatment of complex aortic aneurysms and can be achieved using several techniques, sites and sides. The purpose of this study was to evaluate different UEA strategies in a multicenter registry of complex endovascular aortic aneurysm repair (EVAR).

METHODS

In six aortic centers in the Netherlands, all endovascular aortic procedures from 2006 to 2019 were retrospectively reviewed. Patients who received upper extremity access during complex EVAR were included. Primary outcome was a composite endpoint of any access complication, excluding minor hematomas. Secondary outcomes were access characteristics, access complications considered individually, access reinterventions and incidence of ischemic cerebrovascular events.

RESULTS

417 patients underwent 437 UEA for 303 fenestrated/branched EVARs, and 114 chimney EVARs. Twenty patients had bilateral, 295 left-sided, and 102 right-sided UEA. 413 approaches were performed surgically and 24 percutaneously. Distal brachial access was used in 89 cases, medial brachial in 149, proximal brachial in 140 and axillary access in 59 cases. No significant differences regarding the composite endpoint of access complications were seen (DBA 11.3% vs. MBA 6.7% vs. PBA 13.6% vs. AA 10.2%; p=.29). Postoperative neuropathy occurred most after proximal brachial access (DBA 1.1% vs. MBA 1.3% vs. PBA 9.3 % vs. AA 5.1%; p=.003). There were no differences in cerebrovascular complications between access sides (right 5.9% vs. left 4.1% vs. bilateral 5%; p=.75). Significantly more overall access complications were seen after a percutaneous approach (29.2% vs. 6.8%; p=.002). In multivariate analysis the risk for access complications after open approach was decreased by male gender (OR 0.27; CI 95% 0.10 - 0.72; p= .009), while an increase in age per year (OR 1.08; CI 95% 1.004 - 1.179; p=.039) and diabetes mellitus type 2 (OR 3.70; CI 95% 1.20 - 11.41; p= .023) increased the risk.

CONCLUSION

Between the four access localizations, there were no differences in overall access complications. Female gender, diabetes mellitus type 2 and ageing increased the risk for access complications after surgical approach. Furthermore, a percutaneous upper extremity access resulted in higher complication rates than a surgical approach.

Percutaneous trans-axilla transcatheter aortic valve replacement

The left axillary artery is an attractive alternative access route for transcatheter aortic valve replacement (TAVR) and may provide better outcomes compared to other alternatives. Nevertheless, there remain concerns about vascular complications, lack of compressibility, and thorax-related complications. Between March 2019 and March 2021, 13 patients underwent transaxillary TAVR for severe aortic stenosis at the University Hospital Bonn. The puncture was performed with a puncture at the distal segment of the axillary artery through the axilla, with additional femoral access for applying a safety wire inside the axillary artery. Device success was defined according to the VARC 2 criteria. The study participants were advanced in age (77 ± 9 years old), and 54% were female, with an intermediate risk for surgery (STS risk score 4.7 ± 2.0%). The average diameter of the distal segment of the axillary artery was 5.8 ± 1.0 mm (i.e., the puncture site) and 7.6 ± 0.9 mm for the proximal axillary artery. Device success was achieved in all patients. 30-day major adverse cardiac and cerebrovascular events were 0%. With complete percutaneous management, stent-graft implantation was performed at the puncture site in 38.5% of patients. Minor bleeding was successfully managed with manual compression. Moreover, no thorax-related complications, hematomas, or nerve injuries were observed. Percutaneous trans-axilla TAVR was found to be feasible and safe. This modified approach may mitigate the risk of bleeding and serious complications in the thorax and be less invasive than surgical alternatives.

Brachial and axillary artery vascular access for endovascular interventions

OBJECTIVES

Endovascular access is usually achieved through the common femoral artery due to its large size and accessibility. Access through the upper extremity can however be necessary due to anatomic reasons, obesity, or peripheral arterial disease. The two main methods of access are surgical cutdown and percutaneous puncture. In this single-centre retrospective cohort study we compared complication risks for both surgical cutdown and percutaneous puncture of an upper arm approach.

MATERIALS AND METHODS

Data was obtained from patients receiving endovascular access through the brachial or axillary artery between 2005 and 2018. A total of 109 patients were included. Patient demographics including age, sex, medical history, smoking status, and actual medication were registered, as well as postoperative complications including hematoma, thrombosis, dissection, infection, pseudoaneurysm, nerve injury, reoperation, and readmission.

RESULTS

Access was achieved through surgical cutdown in 53% (n=58) and through percutaneous puncture in 47% (n=51) of patients. Fifty-eight percent (n=63) received access via the brachial artery and 42% (n=46) via the axillary artery. Complication rate was 25.0% (3 of 12) for surgical cutdown via the brachial artery, 29.4% (15 of 51) for percutaneous puncture via the brachial artery, and 10.9% (5 of 46) for surgical cutdown via the axillary artery. Major complication rate was 8.3% (1 of 12) for surgical cutdown via the brachial artery, 13.7% (7 of 51) for percutaneous puncture via the brachial artery, and 4.3% (2 of 46) for surgical cutdown via the axillary artery. There was no association between baseline patient characteristics and complication rate.

CONCLUSIONS

In this non-randomized retrospective study, surgical cutdown via the axillary artery was the safest option with fewest complications, but selection of patients may have blurred the results. Surgical cutdown and percutaneous puncture seem equally safe in terms of complication rate in the brachial artery.

Percutaneous transAXillary access for endovascular aortic procedures in the multicenter international PAXA registry

BACKGROUND

The aim of the study was to demonstrate the safety and effectiveness of a suture-mediated vascular closure device to perform hemostasis after an axillary artery access during endovascular procedures on the aortic valve, the aorta and its side branches.

METHODS

A physician-initiated, international, multicenter, retrospective registry was designed to evaluate the success rate (VARC-2 reporting standards) of percutaneous transaxillary access closure with a suture-mediated closure device. Secondary end points were minor access vascular complications, transient peripheral nerve injury, stroke, and influence on periprocedural outcomes of puncture technique.

RESULTS

Three hundred thirty-one patients (median age, 76 years; 69.2% males) in 11 centers received a percutaneous transaxillary access during endovascular cardiac (n = 166) or vascular (n = 165) procedures. The closure success rate was 84.6%, with 5 open conversions (1.5%), 45 adjunctive endovascular procedures (13.6%), and 1 nerve injury (0.3%). Secondary closure success was obtained in 325 patients (98%) after 7 bare stenting, 37 covered stenting, and 1 thrombin injection. Introducer sheaths 16F or larger (odds ratio, 3.70; 95% confidence interval, 1.22-11.42) and balloon-assisted hemostasis (odds ratio, 4.45; 95% confidence interval, 1.27-15.68) were associated with closure failure. A threshold of five percutaneous axillary accesses was associated with decreased rates of open conversion, but not with increased primary closure success. Primary closure success was 90.3% in the 175 patients with sheaths smaller than 16F, performed after the first 5 procedures in each center. Temporary nerve injury and stroke were observed in 2% and 4% of patients, respectively.

CONCLUSIONS

Percutaneous transaxillary aortic procedures, in selected patients, can be performed with low rates of open conversion. The need for additional endovascular bailout procedures is not negligible when introducers sheaths 16F or larger are required.

Ultrasound-guided arterial catheterization

Ultrasonography facilitates arterial catheterization compared to traditional palpation techniques, especially in small arteries. For successful catheterization without complications, practitioners should be familiar with the anatomic characteristics of the artery and ultrasound-guided techniques. There are two approaches for ultrasound-guided arterial catheterization: the short-axis view out-of-plane approach and the long-axis view in-plane approach. There are several modified techniques and tips to facilitate ultrasound-guided arterial catheterization. This review deals with the anatomy relevant to arterial catheterization, several methods to improve success rates, and decrease complications associated with arterial catheterization.

Brachial plexopathy as a complication of COVID-19

COVID-19 affects a wide spectrum of organ systems. We report a 52-year-old man with hypertension and newly diagnosed diabetes mellitus who presented with hypoxic respiratory failure due to COVID-19 and developed severe brachial plexopathy. He was not treated with prone positioning respiratory therapy. Associated with the flaccid, painfully numb left upper extremity was a livedoid, purpuric rash on his left hand and forearm consistent with COVID-19-induced microangiopathy. Neuroimaging and electrophysiological data were consistent with near diffuse left brachial plexitis with selective sparing of axillary, suprascapular and pectoral fascicles. Given his microangiopathic rash, elevated D-dimers and paucifascicular plexopathy, we postulate a patchy microvascular thrombotic plexopathy. Providers should be aware of this significant and potentially under-recognised neurologic complication of COVID-19.

Doppler Ultrasound as a Unique Diagnosis Test in Peripheral Arterial Disease

BACKGROUND

The aim of this study was to analyze duplex ultrasound (DUS) and intraoperative angiography concordance for diagnosis of lower limb peripheral artery disease and its value for surgical planning.

MATERIALS AND METHODS

This was a prospective, observational study, including patients who underwent revascularization of the lower limbs during 2018, diagnosed by DUS only or combined with preoperative computed tomography (CT) angiography. The concordance between preoperative DUS or CT angiography and the intraoperative angiography was studied using the Cohen kappa coefficient (k). The degree of agreement between the DUS-based surgical plan and the final surgical technique was also evaluated.

RESULTS

Fifty-one patients were included, with mean age of 71.8 ± 11.96 years (46-94); 23 had chronic kidney disease (45%). In 17 patients (34%), preoperative CT angiography was also performed. DUS showed a sensitivity of 100% (95% confidence interval (CI) [83.3-100%]), 80% (95% CI [50.21-100%,]), and 100% (95% CI [96.43-100%]) at the iliac, femoral, and popliteal sector, respectively, and a specificity of 93.55% (95% CI [83.29-100%]), 95.45% (95% CI [84.48-100%]), and 90.48% (95% CI [75.54-100%]) at the iliac, femoral, and popliteal sector, respectively. The positive predictive value for DUS was 60% (95% CI [7.06-100%]), 88.9% (95% CI [62.8-100%]), and 87.5% (95% CI [68.17-100%]) for the iliac, femoral, and popliteal sectors, respectively, whereas the negative predictive value was 100% (95% CI [98.28-100%]), 91.3% (95% CI [77.61-100%]), and 100% (95% CI, [97.37-100%]). The concordance between DUS and intraoperative angiography showed a k index of 0.587 (P = 0.000) in the iliac sector, 0.799 in the femoral sector (P = 0.000), and 0.699 in the popliteal sector (P = 0.000). The concordance between CT angiography/intraoperative angiography had a k index of 0.71 in the iliac sector (P = 0.0093), 0.566 in the femoral sector (P = 0.006), and 0.5 in the popliteal sector (P = 0.028). DUS-based surgical plan was accurate in 86% of cases (n = 44).

CONCLUSIONS

Our experience suggests that DUS arterial mapping of the femoral and popliteal areas is better than CT angiography and can be considered as a unique preoperative imaging test during the surgical planning in patients undergoing a lower limb revascularization procedure.

Percutaneous AXillary Artery (PAXA) Access at the First Segment During Fenestrated and Branched Endovascular Aortic Procedures

OBJECTIVE

The aim of this study was to assess the feasibility and safety of percutaneous axillary access with vessel closure device closure after puncturing the first segment during endovascular treatment of complex aneurysms with fenestrated and branched endografts (F/BEVAR).

METHODS

The PAXA (Percutaneous AXillary Access) study is a physician initiated, single centre, ambispective, non-randomised study (clinicaltrials.gov: NCT03223311). The primary endpoint was the closure success rate defined as the absence of any vascular injury to achieve haemostasis at the puncture site, requiring any treatment other than manual compression or adjunctive endovascular ballooning. The secondary endpoints were minor access complications, cerebrovascular complication rate, short term access vessel patency, and study cohort anatomical evaluation of the axillary artery.

RESULTS

Sixty-four patients required an upper extremity access during F/BEVAR procedure during study period (November 2016 to July 2019) and were screened for the PAXA study: 59 patients (47 males; median age: 75 years, IQR 69-78) met the study inclusion criteria and were enrolled (one patient had bilateral access). Closure success was obtained in 54 cases (90%) with no open conversion required: five patients received a bare or covered stenting to the AXA and in one patient mechanical failure of the delivery system was recorded. No 30 day permanent peripheral nerve injuries and two non-ipsilateral ischaemic strokes (3.4%) were recorded. Seven patients (12%) had access haematomas managed conservatively associated with closure failure (p = .002), oral anticoagulants therapy (p = .005) and procedure length (p = .028). At short term follow up (6 months), no late complications were observed, and all access vessels were patent.

CONCLUSION

PAXA on the first segment using a large sheath (10-16F) is technically feasible, relatively safe with no need for open conversion but it may require access related secondary endovascular procedures. Further prospective studies are needed to modify the device instruction for use and to put the procedure on label.