Acute Lower Extremity Ischemia Research Articles

Acute Lower Extremity Ischemia Caused by the StarClose Vascular Closure Device

A 35-year-old female underwent endovascular coil embolization of an intracranial aneurysm via her right common femoral artery (CFA) using a 6F vascular sheath for access. The puncture site was closed using a StarClose vascular closure device (Abbott Vascular, Maidenhead, UK). However, the patient complained about increasing numbness of the right lower extremity after the procedure. Physical examination revealed pallor and pulselessness of the right lower limb. A contrast-enhanced computed tomography angiogram revealed occlusion of the vascular lumen at the level of vascular access site. The metallic clip was removed and the right CFA was successfully repaired with restoration of flow and symptom resolution.

GW26-e2507 The Effect of Catheter-directed Thrombolysis with Low-dose Urokinase on Acute Lower Extremity limb Ischemia

To evaluate the safety and effectiveness of catheter-directed thrombolysis therapy with low-dose urokinase for acute lower extremity ischemia limb. Retrospective analysis of clinical data of 50 cases, including 27 males and 23 females, aged 27-81 years old, the onset time of 10 hours to 14 days,

Evaluation of Leg Pain

Few patient complaints offer such a large range of acuity and differential diagnoses as the complaint of leg pain. This is in part due to the multiple organ systems at play, including cardiac, pulmonary, musculoskeletal, neurologic, vascular, and dermatologic. The surgeon is frequently presented with the challenge of identifying and managing these complaints in a variety of settings. Management involves a spectrum from conservative care to surgical intervention where appropriate. The wide array of symptoms, signs, and often contradictory test results can be confusing and frustrating to patients and physicians alike, leading to delays and errors in diagnosis and ineffective management. This review offers a sequential and ordered approach to the evaluation of leg pain. Tables highlight atherosclerotic risk factors, vascular causes of lower extremity pain, the classification of acute limb ischemia, the ankle-brachial index and corresponding peripheral arterial disease, and the revised cardiac risk score for preoperative risk. Figures show bilateral lower extremity ischemia, chronic ischemic changes to the foot, classic dry gangrene, wet gangrene, acute limb ischemia, Charcot foot, segmental waveform and pulse volume recording analysis of the bilateral lower extremities, and angiographic evaluation of patients with aortoiliac and tibial disease. This review contains 10 figures, 5 tables, and 55 references.

Total Occlusion of Abdominal Aortic Endograft Successfully Treated with Axillobifemoral Bypass.

We report a case of total occlusion of a Zenith bifurcated stent graft 16 months after implantation. A 72-year-old man was admitted to our hospital complaining of bilateral lower extremity numbness, followed by severe rest pain 4 h after sudden onset of symptoms. Computed tomography showed total occlusion of the endograft at the mid-portion of the main body. He underwent left axillobifemoral bypass using a reinforced polytetrafluoroethylene T-shaped graft, leading to resolution of symptoms 7 h after onset. Axillobifemoral bypass successfully relieved acute lower extremity ischemia caused by total occlusion of the abdominal aortic endograft.

Outcome of Early Surgical Intervention in Acute Lower Limb Ischemia due to Thromboembolism

Background: Acute lower extremity ischemia is a common vascular disease and considered limb- and life- threatening. The present study evaluated and compared the outcome of early and late surgical intervention in acute lower limb ischemia due to thromboembolism. Methodology: This non randomized comparative parallel study was conducted at the Department of Cardiovascular Surgery, NICVD, Dhaka, Bangladesh from January 2007 to December 2008 for duration of two year. Total 80 patients were enrolled in this study. The patients were divided into equal two groups, Group A, for early surgical intervention (with in 24 hours) and Group B, late surgical intervention (more than 24 hours). Results: Mean (±SD) age of both Group A and Group B was 51.93 (±11.73) and 47.00 (± 11.01) years. Male and female ratio of the total study population was 1.76:1 Pain and absence of pulse distal to occlusion was common for all. Cold extremity, sensory deficit, motor deficit, diminish vascular flow was the commonest findings of both group. In Group A, 57.5% had superficial femoral artery occlusion, 22.5% had iliac artery and 20.0% popliteal artery occlusion. In Group B, 42.5% had superficial femoral artery occlusion, 32.5% had popliteal artery occlusion and 25.0% had iliac artery occlusion. Fasciotomy was performed in 15.0% patients of Group A and in 22.0% patients of Group B. After Fogarty embolectomy in group A and group B had warm extremity (80.0% vs. 65.0%), pulsation distal to occlusion (90.0% vs. 75.0%), intact sensory function (82.5% vs. 67.5%), intact motor function (80.0% vs. 65.0%), and normal vascular flow by Doppler US (80.0% vs. 65.0%). During postoperative period history of bleeding, infection, reperfusion injury, muscle necrosis and limb amputation were 12.5% vs. 10.0%, 5.0% and 7.5%, 17.5% vs. 35.0%, 15.0% vs. 12.5% and 37.5% vs. 32.5% respectively. Conclusion: Duration of embolism may be the significant factor determining the outcomes of the management of acute arterial embolism in the lower extremities. The 24- hour duration of arterial embolism is a crucial factor influencing the surgical the management and early diagnosis and shifting of patients to specified centre as early as possible to save limb as well as life. DOI: http://dx.doi.org/10.3329/cardio.v7i1.20799 Cardiovasc. j. 2014; 7(1): 38-43

Comparative effectiveness of endovascular versus surgical revascularization for acute lower extremity ischemia

Thrombolysis and open surgical revascularization are current options for the treatment of acute limb ischemia (ALI). Despite the several randomized controlled trials comparing the two options, no single treatment can yet be recommended as a universal initial management of ALI. The purpose of this study was to evaluate contemporary endovascular and surgical revascularization for ALI. Consecutive patients with ALI treated with endovascular revascularization (ER) or open revascularization (OR) between 2005 and 2011 were identified and reviewed. Procedural success and outcomes were compared between the two groups. Limb salvage and survival were assessed by time-to-event methods, including Kaplan-Meier estimation and competing-risks regression models. A total of 154 limbs were treated in 147 patients in the ER group, compared with 326 limbs in 296 patients in the OR group. The mean follow-up was 14 ± 18.5 months. The majority of patients presented with Rutherford II ischemia (83% for OR, 90% for ER). In Rutherford II patients, technical success was achieved in 90.7% of the OR group vs 79.9% of the ER group (P = .002), with amputation rates of 10.0% vs 7.2% (P = .35) at 30 days and 16.3% vs 13.0% (P = .37) at 1 year, respectively. In Rutherford II patients with failed bypass graft, technical success rate was 95.0% (OR) vs 75.0% (ER) (P = .001), whereas the amputation rate was 6.3% vs 15.38% (P = .13) at 30 days and 24.1% vs 23.1% (P = .90) at 1 year, respectively. The overall 30-day mortality rate was 13.2% (OR) and 5.4% (ER) (P = .012). Overall amputation rates were 13.5% (OR) vs 6.5% (ER) at 30 days (P = .023) and 19.6% (OR) vs 13.0% (ER) at 1 year (P = .074). The primary patency rate was 57% (OR) and 51% (ER) at 1 year (P = .74). Predictors of limb loss by life-table analysis included coronary artery disease (hazard ratio [HR], 2.0; P = .007) and Rutherford category III (HR, 19.0; P < .001). Predictors of death by life-table analysis included age (HR, 1.03; P < .001), end-stage renal disease (HR, 7.28; P < .001), cancer (HR, 1.65; P = .005), and chronic obstructive pulmonary disease (HR, 1.61; P = .005). In patients presenting with class II ALI, ER or surgical OR resulted in comparable limb salvage rates. Although technical success is higher with OR for patients presenting with failed bypass grafts, the amputation rates are comparable. Overall mortality rates are significantly higher at 30 days and 1 year in the OR group.

Trends in the incidence, treatment, and outcomes of acute lower extremity ischemia in the United States Medicare population

Acute lower extremity ischemia (ALI) is a common vascular surgery emergency associated with high rates of morbidity and mortality. The purpose of this study was to assess contemporary trends in the incidence of ALI, the methods of treatment, and the associated mortality and amputation rates in the U.S. Medicare population. This was an observational study using Medicare claims data between 1998 and 2009. Outcomes examined included trends in the incidence of ALI; trends in interventions for ALI; and trends in amputation, mortality, and amputation-free survival rates. Between 1998 and 2009, the incidence of hospitalization for ALI decreased from 45.7 per 100,000 to 26.0 per 100,000 (P for trend < .001). The percentage of patients undergoing surgical intervention decreased from 57.1% to 51.6% (P for trend < .001), whereas the percentage of patients undergoing endovascular interventions increased from 15.0% to 33.1% (P for trend < .001). In-hospital mortality rates decreased from 12.0% to 9.0% (P for trend < .001), whereas 1-year mortality rates remained stable at 41.0% and 42.5% (P for trend not significant). In-hospital amputation rates remained stable at 8.1% and 6.4% (P for trend not significant), whereas 1-year amputation rates decreased from 14.8% to 11.0% (P for trend < .001). In-hospital amputation-free survival after hospitalization for ALI increased from 81.2% to 85.4% (P for trend < .001); however, 1-year amputation-free survival remained unchanged. Between 1998 and 2009, the incidence of ALI among the U.S. Medicare population declined significantly, and the percentage of patients treated with endovascular techniques markedly increased. During this time, 1-year amputation rates declined. Furthermore, although in-hospital mortality rates declined after presentation with ALI, 1-year mortality rates remained unchanged.

Results of surgical management of acute thromboembolic lower extremity ischemia

Acute lower extremity ischemia secondary to arterial thromboembolism is a common problem. Contemporary data regarding this problem are sparse. This report examines a 10-year single-center experience and describes the surgical management and outcomes observed. Procedural codes were used to identify consecutive patients treated surgically for acute lower extremity embolization from January 2002 to September 2012. Patients presenting >7 days after onset of symptoms, occlusion of grafts/stents, and cases secondary to trauma or iatrogenic injury were excluded. Data collected included demographics, medical comorbidities, presenting clinical characteristics, procedural specifics, and postoperative outcomes. Results were evaluated using descriptive statistics, product-limit survival analysis, and logistic regression multivariable modeling. The study sample included 170 patients (47% female). Mean age was 69.1 ± 16.0 years. Of these, 82 patients (49%) had a previous history of atrial fibrillation, and four (2%) were therapeutically anticoagulated (international normalized ratio ≥2.0) at presentation. Presentation for 83% was >6 hours after symptom onset, and 9% presented with a concurrent acute stroke. Femoral artery exploration with embolectomy was the most common procedural management and was used for aortic, iliac, and infrainguinal occlusion. Ten patients (6%) required bypass for limb salvage during the initial operation. Local instillation of thrombolytic agents as an adjunct to embolectomy was used in 16%, fasciotomies were performed in 39%, and unexpected return to the operating room occurred in 24%. Ninety-day amputation above or below the knee was required during the index hospitalization in 26 patients (15%). In-hospital or 30-day mortality was 18%. Median (interquartile range) length of stay was 8 days (4, 16 days), and 36% of patients were discharged to a nursing facility. Recurrent extremity embolization occurred in 23 patients (14%) at a median interval of 1.6 months. The 5-year amputation freedom and survival estimates were 80% and 41%, respectively. Predictors of 90-day amputation included prior vascular surgery, gangrene, and fasciotomy. Predictors of 30-day mortality included age, history of coronary artery disease, prior vascular surgery, and concurrent stroke. Despite advances in contemporary medical care, lower extremity arterial embolization remains a condition that is associated with significant morbidity and mortality. Furthermore, the condition is resource-intensive to treat and is likely preventable (initially or in recurrence) in a substantial subset of patients.

Muscle Fiber Viability, a Novel Method for the Fast Detection of Ischemic Muscle Injury in Rats

Acute lower extremity ischemia is a limb- and life-threatening clinical problem. Rapid detection of the degree of injury is crucial, however at present there are no exact diagnostic tests available to achieve this purpose. Our goal was to examine a novel technique - which has the potential to accurately assess the degree of ischemic muscle injury within a short period of time - in a clinically relevant rodent model. Male Wistar rats were exposed to 4, 6, 8 and 9 hours of bilateral lower limb ischemia induced by the occlusion of the infrarenal aorta. Additional animals underwent 8 and 9 hours of ischemia followed by 2 hours of reperfusion to examine the effects of revascularization. Muscle samples were collected from the left anterior tibial muscle for viability assessment. The degree of muscle damage (muscle fiber viability) was assessed by morphometric evaluation of NADH-tetrazolium reductase reaction on frozen sections. Right hind limbs were perfusion-fixed with paraformaldehyde and glutaraldehyde for light and electron microscopic examinations. Muscle fiber viability decreased progressively over the time of ischemia, with significant differences found between the consecutive times. High correlation was detected between the length of ischemia and the values of muscle fiber viability. After reperfusion, viability showed significant reduction in the 8-hour-ischemia and 2-hour-reperfusion group compared to the 8-hour-ischemia-only group, and decreased further after 9 hours of ischemia and 2 hours of reperfusion. Light- and electron microscopic findings correlated strongly with the values of muscle fiber viability: lesser viability values represented higher degree of ultrastructural injury while similar viability results corresponded to similar morphological injury. Muscle fiber viability was capable of accurately determining the degree of muscle injury in our rat model. Our method might therefore be useful in clinical settings in the diagnostics of acute ischemic muscle injury.

Protocolo diagnóstico y terapéutico de la isquemia aguda de las extremidades inferiores

Acute ischemia of the lower limb is a medical-surgical emergency with a significant risk to both life and limb of the patients. Doppler scan helps in the diagnosis and is used to assist in the precise patient categorization of the degree of ischemia by severity and urgency therapeutic. Doppler ultrasonography and angiography can inform us of the etiology. In order to prevent the spread of the thrombus, anticoagulation with heparin infusion therapy is the first therapeutic choice in the initial management of all patients with acute lower extremity ischemia. Surgical treatment choice between thromboembolectomy or bypass depends on the etiology. Endovascular catheter-directed thrombolysis is effective for surgical limb revascularization. Lower extremity four-compartment fasciotomies are performed to prevent post revascularization compartment syndrom. Amputation is the only option in patients whose disease is diagnosed as irreversible limb ischemia.

Late Lower Extremity Ischemia due to Thrombi in an Occluded Graft after Axillary-Femoral Artery Bypass

We experienced a rare case of acute ischemia of the lower extremity due to embolism caused by an occluded prosthetic graft late after axillary-femoral artery bypass. A 67-year-old woman developed acute right lower extremity ischemia 7 years after axillary-femoral artery bypass, which had been performed for lower limb ischemia as a complication of acute aortic dissection (Stanford B). The graft was occluded, and the native vessel had re-canalized by the time of the present admission. She was successfully treated by disconnection of the graft followed by revascularization.

Acute Lower Extremity Ischemia due to the Popliteal Pseudoaneurysm in a 16-year-old Boy with Multiple Exostoses

Osteochondromas or exostoses are the most common benign bone tumors. This is a case of a 16-year-old boy with multiple osteochondromatosis which caused the popliteal pseudoaneurysm and a subsequent distal embolism. Vascular complications, especially acute limb ischemia, caused by osteochondromas are very rare. This abnormality should be searched for when dealing with young patients with acute limb ischemia.

Bilateral lower extremity acute thromboembolism as first presentation for cancer in a child: An interesting report

Although it rarely occurs in children, acute arterial thromboembolism can cause significant morbidity and mortality. Rapid diagnosis and prompt treatment can increase the chances of survival with a functional limb. We describe the case of a 10-year-old boy with acute bilateral lower extremity ischemia due to arterial thromboemboli originating from a rare cancer. We discuss diagnosis of and treatment strategies for acute arterial thromboembolism in the pediatric population, as well as the rare cancer the patient was diagnosed with.

Aneurysmal degeneration of the superficial femoral artery after remote endarterectomy

Superficial femoral artery reocclusion is the most common complication of remote endarterectomy with the Mollring device. We present the first reported case of a male patient who developed aneurysmal degeneration of the superficial femoral artery after a previous left common femoral endarterectomy and superficial femoral remote endarterectomy with popliteal stenting. He underwent thrombolysis with subsequent percutaneous transluminal angioplasty after developing acute left lower extremity ischemia. At 12-month follow-up, he was free of claudication symptoms. This case illustrates the need for close surveillance and discusses possible treatment options for patients with this rare complication.

Endovascular Treatment of Blunt Traumatic Abdominal Aortic Occlusion With Kissing Stent Placement

Blunt traumatic abdominal aortic dissection is extremely rare and potentially deadly. We present the case of a 62-year-old man involved in a frontal car crash. After emergency undergoing laparotomy for bowel injuries, he was referred to our hospital due to acute ischemia of bilateral lower extremities on day 3 after the trauma. Computed tomography and aortography showed an aortobiiliac dissection with complete occlusion. This injury was successfully treated by endovascular treatment with "kissing"-technique stent placement, which appears to be a safe, effective, and minimally invasive treatment.

Acute aortic occlusion from a Candida fungus ball

Fungal arterial infections are well-described entities resulting in direct invasion of the arterial wall or embolic occlusion of small and medium-sized arteries. However, acute occlusion of large vessels such as the aorta by fungal material is exceedingly rare. A 53-year-old woman presented with acute bilateral lower extremity ischemia. She had a history of fungal endocarditis requiring two prosthetic mitral valve replacements; the last episode was 7 months before the current admission. Imaging studies revealed that she had an acute infrarenal aortic occlusion, with evidence of multiple end-organ emboli. After transfemoral thromboembolectomy, perfusion was restored to her lower extremities with minor neurologic sequelae. She ultimately responded to intravenous antifungal agents.

A Role for Embolic Protection in the Management of Acute Limb Ischemia

Distal embolization is a complication during lower-extremity revascularization procedures that may occur when intervening on acute or subacute lesions. Several studies have demonstrated the safety and feasibility of using embolic protection devices (EPD) and some interventionalists have adapted this technology for use in infrainguinal revascularization procedures. At present, there are no randomized trials to indicate the benefit, safety, and cost-effectiveness of EPD for this application and its use in the United States is considered off-label. However, based on our experience and a review of the published literature, we consider the use of EPD in acute lower-extremity ischemia a reasonable strategy.

Acute aortic occlusion in a child secondary to lap-belt injury treated with thromboendarterectomy and primary repair

Abdominal aortic injury as a result of blunt trauma is a rare event and has been described in few children. A 6-year-old girl presented with acute bilateral lower extremity ischemia, and a triad of acute aortic occlusion, intra-abdominal visceral injury, and a lumbar chance fracture after sustaining a seat belt injury from a motor vehicle collision. An emergency aortic thromboendarterectomy and primary repair were performed. This represents one of the few reports of acute traumatic aortic thrombosis in a child and highlights the surgical treatment of acute abdominal aortic injury in a pediatric patient.

Unilateral Acute Lower Extremity Ischemia with Popliteal Artery Aneurysm as a Result of Vascular Type III Entrapment in an Elderly Patient

Popliteal artery entrapment syndrome (PAES) is a rare cause of acute limb ischemia in adult patients but commonly demonstrates as claudication in young patients. The most significant, although rare, complication associated with PAES is aneurysm formation. We present the case of an elderly patient with a unilateral popliteal artery aneurysm owing to symptomatic anatomic entrapment. This report presents the oldest patient ever reported with this syndrome and highlights the advantage of multimodal treatment. As multidetector computed tomography highly contributed to the rapid diagnostic confirmation and choice of treatment in the popliteal fossa, limb salvage was achieved in this patient.

Ruptured Persistent Sciatic Artery Aneurysm Managed by Endovascular Embolization

Persistent sciatic artery (PSA) is a rare vascular anomaly present in 0.025% to 0.05% of the population. They are particularly prone to aneurysmal degeneration, potentially leading to distal ischemia, sciatic neuropathy, or rarely rupture. Here, we describe a case of a ruptured PSA aneurysm managed by endovascular embolization. A 70-year-old man initially presented with acute left lower extremity ischemia. He was found to have a popliteal embolus originating from a complete persistent sciatic artery aneurysm. He underwent thrombolysis followed by a femoropopliteal bypass and ligation of the proximal popliteal artery to exclude the PSA. Four weeks later he re-presented with severe pain, a pulsatile buttock mass, and anemia in the setting of hemodynamic instability. A ruptured PSA aneurysm was confirmed by computed tomography angiography (CTA). This was managed emergently by endovascular exclusion of the inflow and outflow vessels using Amplatzer vascular plugs. His postoperative course was complicated by both a foot drop, likely secondary to sciatic nerve ischemia, and a buttock abscess. To our knowledge, this is the first report detailing the endovascular management of a ruptured PSA aneurysm. The etiology, management, and complications associated with the treatment of this rare vascular entity are discussed.