Acute Leg Ischemia Research Articles

The Classical 6-P of Acute Limb Ischemia

Acute limb ischemia (ALI) is a surgical emergency and often threatens limb viability. This is a case of a 45-year-old patient who presented with the classical six Ps of ALI. A 45-year-old lady with underlying hypertension and heart failure presented with acute right leg pain arriving by ambulance at the Emergency Department within 4 hours of the symptom. The patient was clinically obese and seemed very uncomfortable as evidenced by her writhing in pain. She was borderline tachycardic and hypertensive. The cardiopulmonary and abdominal examinations were unremarkable. On extremity examination, she was unable to move her right leg starting from the knee caudally. The leg appeared mottling and cold. On vascular examination, there was no abdominal or femoral bruit but there was a diminished pulsation of the right femoral, dorsalis-pedis and posterior-tibialis arteries as confirmed by Doppler compared to the contralateral side. On the neurological examination, the sensation was absent and no pain upon the passive stretch. Ankle-Brachial-Systolic Index (ABSI) was 0.7. As evidenced by pain, pallor, pulselessness, poikilothermia, paralysis, and paresthesia, clinical diagnosis of acute right leg ischemia was established with most likely vascular occlusion proximal to the left femoral artery. The vascular team was urgently referred. Electrocardiogram showed sinus tachycardia. Bedside ultrasound revealed normal aortic root size and neither aortic dissection nor aneurysm. 2-point compression tests were fully compressible and X-ray films showed no fracture. Creatinine Kinase was 65 units/litre whereas other blood parameters were unremarkable. She was then classified as Rutherford IIB and underwent a right femoral thromboembolectomy. The presentation of ALI requires rapid diagnosis and appropriate management as it is time-sensitive and limb-threatening. Emergency physicians should be aware of advances in endovascular therapies as a recommended option for the treatment of ALI. International Journal of Human and Health Sciences Supplementary Issue: 2023 Page: S23

Bleeding Issues During Thrombolysis for Acute Leg Ischaemia

Bleeding Issues During Thrombolysis for Acute Leg Ischaemia

Severe inframalleolar disease is an independent predictor of adverse limb outcomes after endovascular revascularization in chronic limb-threatening ischemia

ObjectiveIn the present study, we evaluated the effects of inframalleolar (IM) disease on the occurrence of major adverse limb events (MALE) in patients undergoing endovascular revascularization for chronic limb-threatening ischemia (CLTI). MethodsPatients who had undergone endovascular revascularization for CLTI between January 2015 and December 2019 at two university-affiliated hospitals were reviewed retrospectively. Patients with severe IM disease (pedal score of 2) were compared with those with mild to moderate IM disease (score of 0 or 1) using the Global Vascular Guidelines. The primary outcome was MALE (open revascularization, acute leg ischemia, major amputation). The secondary outcomes were mortality, reintervention, major adverse cardiac events, and perioperative complications ≤30 days after endovascular revascularization, primary limb-based patency, and the occurrence of any limb event (defined as any amputation, acute leg ischemia, or open revascularization). Kaplan-Meier estimates were used to compare the primary outcome, and the Cox proportion hazard model was used to assess the effects of IM disease. ResultsThe study included 167 limbs in 149 patients (36% female; mean age, 74 ± 12 years). Severe IM disease was identified in 71 limbs (43%). No differences were found in the baseline characteristics, except for a higher prevalence of dyslipidemia in the patients with severe IM disease (66% vs 43%; P = .003). Most patients in both groups had had a WIfI (Wound, Ischemia, foot Infection) score of 4 (severe IM disease, 64%; vs mild to moderate IM disease, 57%; P = .462) and GLASS (global limb anatomic severity scale) III anatomy (severe IM disease, 54%; vs mild to moderate IM disease, 48%; P = .752). The Kaplan-Meier estimates showed that severe IM disease was associated with lower freedom from MALE (69% vs 82%; P = .026). The Cox proportion hazard regression model showed that severe IM disease was an independent predictor of increased MALE and amputation risk (hazard ratio, 1.715; 95% confidence interval, 1.015-2.896; P = .044) after adjusting for covariates. During follow-up, patients with severe IM disease had had mortality (27% vs 31%; P = .567) and reintervention (42% vs 38%; P = .608) similar to those for patients with mild to moderate IM disease. Primary limb-based patency was also similar (79% vs 84%; P = .593) at a mean follow-up of 3.8 ± 0.8 years. ConclusionsSevere IM disease was prevalent in 43% of limbs that had undergone endovascular revascularization for CLTI and was associated with lower freedom from MALE. Severe IM disease also independently increased the hazard of adverse limb outcomes and amputations in patients with CLTI by >70%, highlighting its importance as a measure of foot perfusion.

Contrast enhanced magnetic resonance imaging in early assessment of atherosclerotic lesion of abdominal aortic wall and common iliac arteries

Highlights. Early atherosclerotic changes in the abdominal aortic wall and common iliac arteries in patients without clinical manifestations of critical atherosclerotic stenosis of the lower extremity arteries were studied using contrast enhanced magnetic resonance imaging. A method for quantitative characterization of the accumulation of paramagnetic contrast in the abdominal aortic wall and common iliac arteries is presented.Aim. To study the pattern of early atherosclerotic lesions of the abdominal aortic wall and common iliac arteries in patients without clinical manifestations of critical atherosclerotic stenosis of the lower extremity arteries using paramagnetic contrast enhancement (CE-) MRI.Methods. The retrospective study included 36 patients (25 men, 11 women) who underwent MRI of the lumbar spine with CE, without signs of atherosclerosis of the lower extremities. Subsequently, 2.5 and 4 years after CE-MRI, two patients developed acute leg ischemia and required vascular surgeries. At the time of the study, both had higher levels of C-reactive protein in the blood (6.3 mg/L and 5.9 mg/L, while the other patients had <4.2 mg/L). MRI included T2 – and T1-weighted spin-echo scans (T2-w and T1-w) in the axial and sagittal planes, before and in 10-15 minutes after contrast injection. The index of enhancement (IE) of T1-w was calculated based on the ratio of mean intensities of the region of arterial wall over aorta and iliac arteries in CE-MRI and pre-contrast MRI: IE = Int.T1–w. CE / Int. T1–w pre-contrast.Results. Depending on the IE of the abdominal aortic wall in CE-MRI, patients were divided into three groups: group 1 (n = 11) with IE ≤1.05; group 2 (n = 16) with 1.05 <IE ≤1.15; group 3 (n = 9) with IE >1.15. The aortic IE in all three groups was 1,03 (1,01;1,03); 1,10 (1,09;1,15); 1,36 (1,16;1,40) respectively (p<0.001). The thickness of the abdominal aortic wall progressively increased moving up the group 1, while statistically significant differences were found only between the groups 1 and 3, and the groups 2 and 3 (p<0.001). There were no differences in the wall thickness of the common iliac arteries and the diameter of all vessels studied between the groups. Two patients from the group 3 later presented with acute limb ischemia.Conclusion. The state of the abdominal aortic wall and common iliac arteries should be evaluated, and IE of T1-w should be calculated when performing CE-MRI examination of the area of the descending aorta to assess pathological neoangiogenesis as the most important component of atherogenesis.

Is it justified to search for cancer in patients with peripheral arterial disease?

Cancer is the leading cause of death in European countries, ahead of cardiovascular diseases. Cancer is also the most common co-morbidity among patients hospitalized for the management of cardiovascular diseases. Through an overview, we searched for the frequency and types of cancer associated with peripheral arterial disease (PAD) in order to address the relevance of cancer screening in patients with PAD. We searched in PubMed database from 1996 to 2020 for retrospective and prospective cohort or cross-sectional or randomized studies evaluating the frequency of all types of cancer in patients with PAD excluding patients with aneurysmal disease. The keywords used were: peripheral arterial disease, arterial thrombosis, acute leg ischemia, critical leg ischemia, chronic leg ischemia, intermittent claudication, malignant tumor, cancer. Based on published studies, the frequency of cancer in patients with PAD varied widely from 3.8 to 30.4% depending on study design, population, method used to screen for cancer and study period. In medical records database and registers,cancer prevalence varied from 3,8% to 22,4% in 4 retrospective studies of patients with acute limb ischemia and from 10.5 to 30.4% in 3 prospective studies of patients with acute limb ischemia, critical ischemia or intermittent claudication. In 3 retrospective analyses from 2 population-based cohorts and health insurance claims data, incidence of cancer in patients with intermittent claudication, acute limb ischemia or peripheral arterial disease varied from 8% to 11.7%. The frequency of cancer in PAD patients appeared higher than in the general population. Tobacco-dependent cancers seemed to be the most common cancers in PAD. Cancers were also more frequent in case of anemia, amputation and iterative bypass thrombosis in few studies. Although there is no recommendation for cancer screening in patients with PAD, the high prevalence of cancer raises the question of screening patients at high risk such as those with acute or critical limb ischemia and especially in case of severe tobacco use, anemia, amputation and iterative bypass thrombosis. These results call for further studies with larger sample size and long term follow-up.

Acute Leg Ischaemia: Call to Arms

This paper by Kulezik et al.1 uses the same methodology as our study done in Gloucestershire, UK, 25 years ago.2 Both research teams attempted to identify all episodes of acute leg ischaemia (ALI) in a defined area. Both share the same limitations on case ascertainment, but are the best information currently available.

Are Small Popliteal Aneurysm so Innocent?

We recently recorded 5 lower limb ischemia related to a small (diameter≤20 mm) popliteal artery aneurysm (PAA) thrombosis hence we performed a retrospective data analysis on small symptomatic PAA management from our database. We performed a retrospective cohort study on 48 acute leg ischemia from aneurysm's thrombosis. All of them underwent surgical distal thrombectomy and bypass creation. Patients were divided into 2 different cohorts: GROUP A (diameter ≥20 mm) and GROUP B (diameter ≤20 mm). Differences in terms of the limb salvage (end-point: the amputation rate) was analyzed and considered significative for P ≤ 0.05. Secondary objectives were: vessel runoff recovery and patency rate. Adverse events were collected at 12 and 24 months postoperative. Two-year overall amputation rate was: 22.9% (11/48); 21.8% (7/32) in GROUP A and 25% (4/16) in GROUP B (RR:0.87, CI:0.29-2.55, p.80). The mean age was 68 ± 13 years, No statistically significant differences were identified in term of primary and secondary patency (RR:0.95, CI:0.55-1.6, p.85 and (RR:0.95, CI:0.53-1.7, p.88 respectively) no differences were found in terms of comorbidities. Patients' follow-up ranged from 8 to 36 months. In 90% of those amputated patients, the length of ischemia exceeded 4 days. Amputation rate was correlated with one runoff vessel recovery, only. s According these results small PAA are not as innocent as it is often presumed and was associated with not negligible incidence of limb loss due to thrombosis or distal embolizations also if compared to larger aneurysm. The immediate surgery is mandatory also when the ischemia exceeds 2 days.

Is Surgical Thrombo-Embolectomy in Acute Limb Ischemia Still Advantageous in Patients More Than 65 Years of Age?

In this study, we investigated the benefits of using Fogarty balloon catheterization in the treatment of acute leg ischemia with respect to amputation, fasciotomy, and mortality in older patients. A total of 102 patients age >65 who had a Fogarty thrombo-embolectomy for acute thromboembolic limb ischemia were investigated retrospectively. Patients were evaluated based on Rutherford IIa and IIb criteria and duration of ischemia. Duration of ischemia was divided into 3 categories (as 0 to 4, 4 to 8, and >8 hours) to evaluate the effect of ischemia period on vital parameters and mortality. Analysis with Cox regression showed that 30-day mortality was associated with older age and number of comorbidities such as amputation and fasciotomy. In 102 patients >65 years of age who underwent embolectomy, rates were 7.2% fasciotomy (n = 7) and 13.7% amputation (n = 14), and 10 patients died (9.8%). According to multiple regression analysis, the surgical risk increases 1074 times when each year is added to the chronological age of over 65 years. In a majority of cases, limb salvage can be obtained via simple embolectomy rather than risking intravenous iodinated contrast. Although alternatives in older patients are limited, the Fogarty catheter should be regarded as a first-line treatment because of its ease of use and low complication rate.

Iatrogenic tibial arteriovenous fistula after Fogarty balloon catheter graft thrombectomy.

A 75‐year‐old male presented with an immediately threatened grade IIb acute ischemia of the left leg due to thrombosis of a femoro‐infrapopliteal prosthetic bypass graft. After an urgent Computed Tomography Angiography, an urgent graft thrombectomy was performed using a 5 Fr Fogarty catheter, which had a troublesome distal passage, causing a tibial A‐V fistula.

Thrombosed Abdominal Aortic Aneurysm with Horseshoe Kidney Presenting with Acute Limb Ischemia

Acute thrombosis of an abdominal aortic aneurysm with a horseshoe kidney (HSK) is a very rare phenomenon. This anatomical anomaly poses a challenge for the surgeon which requires prompt treatment. We present a case report of an elderly man who presented with a threatened acute left leg ischemia and a pulsatile abdominal mass. Computed tomography revealed a huge fusiform infrarenal aortic aneurysm extending to the left iliac artery with thrombotic occlusion and a HSK. He underwent emergency transabdominal laparotomy and aneurysectomy with inlay bifurcated graft repair. The renal isthmus was preserved and left accessory renal artery was reimplanted onto the graft. Postoperatively, bilateral lower limb was viable and kidney function was normal. He was discharged well. Open surgery remains the gold standard in treating such a complex case promptly.

Intraarterial Injection of Drugs of Abuse into Femoral Artery: Case Report and Review of the Literature

Accidental intraarterial injection is a serious condition which can compromise the viability of the limb within hours. There are no evidence based guidelines suggesting the proper treatment protocol and there is no consensus about the ideal treatment for these events. We present a case where a mixture of benzodiazepine pills and street heroin was injected in right femoral artery. Patient arrived in hospital days after event. With intraarterial application of thrombolysis, vasodilators and heparin major amputation was avoided. It seems that in selected cases combined therapy with rtPA lysis and PGE1 intra-arterial infusion may prevent major limb amputation even in delayed presentation of acute leg ischaemia caused by inadvertent injection of drugs of abuse.

Outcome of percutaneous transluminal angioplasty for subacute lower limb ischemia

Context Management of acute limb ischemia ( Aim The aim of this study was to evaluate the clinical and hemodynamic outcome of percutaneous transluminal angioplasty for subacute lower limb ischemia. Settings and design A total of 22 limbs that presented with subacute leg ischemia admitted to Alexandria Main University Hospital have been studied prospectively. All patients had femoro-popliteal occlusions shown by multislice computed tomographic angiography and severe leg ischemic pain +/− crippling claudication. Patients with acute leg ischemia or extensive foot necrosis necessitating amputation were excluded from the study. Patients and methods All patients were subjected to ankle-brachial index (ABI) measurement, color duplex ultrasound (CDU) scan, and multislice computed tomographic angiography before intervention. Percutaneous transluminal angioplasty (balloon angioplasty +/− stent deployment) was performed for all participants. Clinical follow-up with ABI measurement was done at 1-, 3-, and 6-month intervals. CDU after 6 months for patency and restenosis was performed. Statistical analysis Statistical Package for the Social Sciences, version 15.0 was used. Values were compared with a paired samples t test. P values less than 0.05 were considered significant. Results Mean follow-up period was 6.2 months. The mean (±SD) ABI before and at 1-, 3-, and 6-month interval was 0.4 (±0.2), 0.53 (±0.11), 0.62 (±0.12), and 0.86 (±0.16), respectively, with P value less than 0.0001. Limb salvage rate for those patients who had constant ischemic pain and had primary technical success was 89%. As for those patients who had severe claudication, at 6-month follow-up, they had no complaint. Primary patency rate by CDU was 95%. Conclusions Balloon angioplasty is a safe and effective tool for management of subacute leg ischemia. It avoids high surgical risks and carries promising patency and limb salvage rates.

Venous or arterial thromboses after venoarterial extracorporeal membrane oxygenation support: Frequency and risk factors

Although venous thrombosis after venovenous-extracorporeal membrane oxygenation (ECMO) is well described, vascular complications occurring after venoarterial ECMO (VA-ECMO) removal have not yet been thoroughly described. Our aim was to evaluate the frequency of vascular (arterial and venous) complications after VA-ECMO removal and try to identify the risk factors associated with them. Retrospective analysis of data prospectively collected in 2 intensive care units was performed. Consecutive patients successfully weaned off VA-ECMO during year 1 were screened for cannula-associated deep vein thrombosis (CaDVT) or arterial complications (arterial thrombosis/stenosis) using Doppler ultrasonography. From November 2018 to November 2019, a total of 107 patients with a median (interquartile range [IQR]) age of 54 (42-63) years and a median (IQR) ECMO support duration of 8 (2-5) days were successfully weaned off VA-ECMO and included. CaDVT occurred in 44 patients (41%), and arterial complications occurred in 15 (14%) (9 acute leg ischemia, 1 arteriovenous femoral fistula, and 5 late femoral stenosis). Multivariable analysis retained longer duration of ECMO support (odds ratio [OR]: 1.12 per day; 95% CI: 1.02-1.22) and infection occurring on ECMO (OR: 3.03; 95% CI: 1.14-8.03) as independent risk factors for CaDVT, whereas older age (OR: 0.97 per year; 95% CI: 0.94-0.99) and previous anti-coagulation use (OR: 0.21; 95% CI: 0.06-0.68) were protective factors for CaDVT. No risk factors for arterial complications were identified. In patients requiring VA-ECMO support, vascular complications occurred frequently after its removal, especially CaDVT. Arterial complications, either early leg ischemia or late arterial stenosis, were observed less often. Strategies aimed at preventing CaDVT after VA-ECMO remain to be determined.

Acute peripheral ischemia in healthy female patient: an indirect and unanticipated diagnosis of spontaneous thrombus in the aortic arch

BackgroundIn this case we discuss the management of a pediculated floating thrombus in the aortic arch which led to peripheral embolization and acute ischemia oft he left leg.Case presentationA healthy 46 year old female patient presented with pain in her left leg and progressive numbness. Computed Tomography Angiography (CTA) showed an acute ischemia of the left leg (Rutherford 2 B) with a 2 cm thrombus distal of the aortic bifurcation. Emergency operation with embolectomy, selective thrombembolectomy and patch plasty on the tibioperoneal trunk and local lysis was performed. As part of a further diagnostic examination a thoracic CT scan has been performed revealing a pediculated-floating 2 cm thrombus in the aortic arch. Four days after the initial operation thrombus excision via a minimally invasive access way has been performed. After initiation of the extracorporeal circulation, selective unilateral antegrade cerebral perfusion has been established in mild (30–32 °C) systemic hypothermia. Patients postoperative course was uneventful. Histological evaluation of the mass demonstrated thrombotic material without evidence of infection or malignacy.ConclusionA pediculated spontaneous thrombus may develop in aortic arch in patients without traditional risk factors or family history of embolic events. Two stage operation was feasible and safe.

Outcomes of Catheter-Directed Thrombolysis of Autogenous Vein Bypass Versus Prosthetic Bypass for Acute Leg Ischemia

Outcomes of Catheter-Directed Thrombolysis of Autogenous Vein Bypass Versus Prosthetic Bypass for Acute Leg Ischemia

Major vascular complications after transfemoral arterial closure system implantation: a single-center study.

During the past decades, the use of vascular closure devices (VCDs) has been established due to the increasing number of interventions. Of particular concern is the perceived risk of VCDs for development of implant-induced vascular major complications. Therefore, the aim of this analysis was to report the variety of vascular access side complications after the use of VCDs, and to analyze the referred risk factors. All cases of vascular complications associated with VCD use requiring surgical repair from 2010 to 2016 were retrospectively analyzed in a single center trial. Systemic and local complications, risk factors as pre-existing diseases and their influence on the surgical outcome were evaluated. A total of 46 individuals were included in this study (male/female: 16/30). The total number of interventions in the involved departments of the study center during the same period was 9754 Therefore the complication rate after VCD implantation was 0.47%. The detected complications ranged from symptomatic claudication (N.=24) to acute leg ischemia (N.=19) and major bleeding (N.=3). Surgical reconstruction was performed by direct suture (N.=4), transverse arteriotomy with thrombectomy (N.=2), endarterectomy with patchplasty (N.=35), inguinal graft interposition or bypass (N.=3) and primary major amputation (N.=2). In regard to the risk factors, the study has concluded that atherosclerosis, female gender and diabetes mellitus are correlated with major vascular complications (bleeding and limb ischemia). However, in cases with therapeutic anticoagulation the rate of major bleeding was significantly elevated (P=0.028). Reported complication rates associated with femoral VCD implantation are low. However, in some cases VCD implantation may account for severe complications including limb losses. Therefore, an adequate patient selection is necessary to detect those cases at higher risk for complications.

TCTAP C-169 Acute Ischemia of Right Leg in Bilateral Persistent Sciatic Artery

TCTAP C-169 Acute Ischemia of Right Leg in Bilateral Persistent Sciatic Artery

Percutaneous Mechanical Thromboembolectomy in Acute Lower Limb Ischemia.

To analyze the immediate outcome of percutaneous mechanical thromboembolectomy in acute infrainguinal leg ischemia in a consecutive cohort of patients with acute lower limb ischemia. We retrospectively analyzed the data of 156 acute infrainguinal ischemic events in 148 patients. Patients presented with acute limb ischemia Rutherford category I in 68 cases (44%), Rutherford category II A in 64 instances (41%) and Rutherford II B in 24 instances (15%). In 62 cases (39.7%), the occlusion site started below the knee joint level, in 94 (60.3%) cases above. As a basic technique, an intervention was started by manual aspiration but if aspiration failed, an additional device was added. Most frequently, a rotational thrombectomy device (Rotarex, Straub Medical, Wangs, Switzerland) was used. An antegrade access to the femoral artery was the preferred access to the limb (154/156). In 145 of 156 incidents, a technical success was achieved (93%). Aspiration was used in 153 cases (98%). Rotational thrombectomy by use of the Rotarex catheter was added in 60 cases (38%). Directional atherectomy was applied in a total of five patients. As main technical complications, a downward embolization occurred (n = 11). There were four surgical groin revisions. Five patients died during the early follow-up with four not related to the intervention. Clinically, 135 patients (86.5%) showed an improvement in their clinical situation. Acute lower limb ischemia can be successfully treated by mechanical thromboembolectomy only by combining aspiration embolectomy with rotational thrombectomy in most cases but manual aspiration alone will frequently fail especially above the knee joint level.

Akut Bacak İskemisinin Hibrit Yaklaşımla Başarılı Tedavisi

Akut Bacak İskemisinin Hibrit Yaklaşımla Başarılı Tedavisi

PP-167 - A Rare Cause of Acute Leg İschemia: Popliteal Artery Aneurysm

Introduction: Popliteal artery aneurysms are rarely seen, but thromboembolic complications they may cause may also lead to loss of intact extremity. Primary complications include rupture, distal embolization, and thrombosis. Post-thrombosis acute leg ischemia may be the first clinical sign.