Acute Leg Ischemia Research Articles

National Audit of Thrombolysis for Acute Leg Ischemia (NATALI): Clinical Factors Associated With Early Outcome

National Audit of Thrombolysis for Acute Leg Ischemia (NATALI): Clinical Factors Associated With Early Outcome

Occlusion of the Popliteal Artery in Hereditary Multiple Exostosis Syndrome

IntroductionHereditary multiple exostosis syndrome is a rare condition which can occasionally cause arterial occlusion. Case reportA 50-year-old man was treated for acute leg ischaemia but no cause found. Two years later, acute ischaemia recurred and attempts at limb salvage failed. Hereditary multiple exostosis syndrome was then recognised as the cause due to a femoral exostosis compressing the popliteal artery. DiscussionThe case highlights a rare cause of acute limb ischaemia and emphasises the importance of arterial imaging when no embolic source is found.

Occlusion of the Popliteal Artery in Hereditary Multiple Exostosis Syndrome

IntroductionHereditary multiple exostosis syndrome is a rare condition which can occasionally cause arterial occlusion. Case reportA 50-year-old man was treated for acute leg ischaemia but no cause found. Two years later, acute ischaemia recurred and attempts at limb salvage failed. Hereditary multiple exostosis syndrome was then recognised as the cause due to a femoral exostosis compressing the popliteal artery. DiscussionThe case highlights a rare cause of acute limb ischaemia and emphasises the importance of arterial imaging when no embolic source is found.

Surgical management of acute carotid thrombosis after carotid stenting: A report of three cases

We report three cases of symptomatic acute carotid thrombosis occurring after carotid artery stenting (CAS). CASE 1: A patient presented with crescendo transient ischemic attacks on the second day after CAS. Ultrasound images demonstrated incomplete in-stent thrombosis due to plaque protrusion. The urgent surgical procedure consisted of stent removal and carotid thromboendarterectomy. CASE 2: A case of complete thrombosis of a carotid stent occurred 4 days after implantation in a patient with essential thrombocythemia diagnosed by chance. The surgical strategy included stent removal and carotid thromboendarterectomy. CASE 3: Cardiac multiple embolisms in a patient with chronic atrial fibrillation caused concomitant leg ischemia and acute carotid stent occlusion 2 hours after CAS. Cerebral reperfusion was established by embolectomy, without removing the stent. At the same time, the right leg ischemia was resolved by a thromboembolectomy with a Fogarty catheter. These three cases demonstrate that acute thrombosis after carotid stenting can be managed successfully with emergent surgical intervention. Thromboendarterectomy with stent removal or in selected cases, simple thromboembolectomy, can minimize neurologic sequelae in patients suffering from acute post-stenting carotid thrombosis.

Association of malignant disease with critical leg ischaemia

The aim of the study was to determine the prevalence of malignant disease in patients with critical leg ischaemia (CLI). : Data for all patients with CLI presenting to a tertiary vascular unit over an 18-month interval were collected prospectively. Patients with clinical, laboratory or radiological features suggestive of malignancy were evaluated further. Of 192 patients admitted with CLI, 22 (11.5 per cent) were found to have an associated malignancy; ten had lung cancer. Fifteen were anaemic on presentation. The prevalence of occult malignancy in patients with acute leg ischaemia was 16 per cent (ten of 62) compared with 9.2 per cent (12 of 130) in those with chronic CLI. Eleven of 22 of patients with CLI and malignancy died within 6 months, compared with 35 (20.6 per cent) of 170 patients with no evidence of malignancy. A high prevalence of occult cancer was found in patients presenting with CLI; this was associated with a significantly increased mortality rate at 6 months.

Ischémie subaiguë d’un membre inférieur révélant une hyperhomocystéinémie chez une femme jeune

A 51-year-old woman had no known cardiovascular risk factor. She presented with bilateral calf intermittent claudication from February. She was hospitalized in August for acute right leg ischemia without loss of sensorymotor functions, following angiography by one week. She had an occlusion of both superficial femoral arteries and abdominal aorta thrombus, plausible source for embolism. Her condition quickly improved with heparin and iloprost infusion. Since the aortic thrombus was removed on ultrasound, aortic surgery was not performed at this time. Investigations showed hyperhomocysteinemia (25 μg/L after overnight fasting and 115 after methionin load) and decrease in folic acid. This report highlights the occurrence of severe arterial disease in young women with high serum homocysteine levels. (J Mal Vasc 2005; 30: 178-180)

Endocardites non infectieuses : étude rétrospective (6 cas)

If there is cardiac valve vegetation and the blood cultures are negatives we need to look for slow growing bacteria, fungi, Legionella pneumophilia, Bartonella henselae and quintana, Brucella melitensis and abortus, Coxiella burneti, Chlamydiae pneumoniae by serologic tests. The diagnosis of non- infectious endocarditis could be considered only if these results were negative. The main purpose of this study was to describe the clinical and echocardiographic signs of non-infectious endocarditis cases observed in two different wards. This study was done retrospectively during a five-year period in a cardiology and an internal medicine wards. The selection criteria are: the proof of at least one cardiac valve vegetation, observed on echocardiography, negative blood cultures and negative serologic tests as described above. Six non-bacterial endocarditis were described. Four Libman-Sacks endocarditis, two associated with a primary antiphospholipid syndrome revealed by an acute ischemia of leg for one patient and by an eclampsia for another and the other two associated with a systemic lupus erythematous revealed by fever for one patient and by neurologic symptoms for the other. One fibroblastic endocarditis associated to an essential hypereosinophilia and one marastic endocarditis associated to a metastatic mucin-producing cancer. For these six cases, a complete physical examination, a CBC for hypereosinophylia, a dosage of antiphospholipid antibodies and a thoraco-abdominal CT-scan allowed the etiologic diagnosis of non infectious endocarditis. Libman Sacks endocarditis associated with an antiphospholipid syndrome is the main etiology for which a long-term anticoagulation treatment was not followed.

External Femorofemoral Bypass to Relieve Acute Leg Ischemia during Circulatory Assist

The development of limb ischemia in patients who are dependent on an intra-aortic balloon pump (IABP) and/or extracorporeal membrane oxygenation (ECMO) is a serious problem. We used external femorofemoral bypass grafting at the bedside as a salvage procedure in two such patients with effective reversal of ischemia, although both died of cardiac complications. This procedure can be considered in patients who are severely coagulopathic and are dependent on IABP and/or ECMO, in whom the graft removal would be considered at the time of balloon removal.

Treatment of acute lower limb ischemia following the use of the Duett sealing device: report of three cases and review of the literature.

Three cases of local thrombolysis in the treatment of acute lower limb ischemia complicating the utilization of the Duett sealing device are presented. Routine usage of several vascular closure devices after cardiac catheterization and percutaneous coronary intervention (PCI) has been adopted in our institution during the last 3 years (September 1999 to April 2003). The Duett closure device has been used in 420 patients (post-coronary angiography, 359; post-PCI, 61). Three patients (0.7%) demonstrated acute leg ischemia used by inadvertent intravascular administration of the sealing material related to this device. All three were treated successfully by catheter-directed local thromolysis (tissue plasminogen activator 5 mg bolus followed initially by 1 mg/hr and consequently by 0.5-1.0 mg/hr depending upon the development of significant hematoma and lasting for 24 hr). In conclusion, interventional treatment using local thrombolysis should be the first-line treatment in acute lower limb ischemia complicating the utilization of the Duett sealing device.

National Audit of Thrombolysis for Acute Leg Ischemia (NATALI): clinical factors associated with early outcome

Objective The National Audit of Thrombolysis for Acute Leg Ischemia (NATALI) database is a consecutive series of patients who underwent intra-arterial thrombolysis to treat acute leg ischemia in one of 11 centers in the United Kingdom. The purpose of the study was to analyze the factors associated with outcome after 30 days. Methods The data were collected over 10 years on standard pro formas, and registration was completed at the end of 1999. Since then, data from each unit have been verified and missing data included when available. Univariate and multivariate analyses were performed, with the outcomes of amputation-free survival (AFS), amputation with survival, and death. Results A total of 1133 thrombolytic events were included. Outcome results at 30 days for the entire group were AFS, 852 (75.2%); amputation, 141 (12.4%); and death, 140 (12.4%). Results for the entire group improved from the first half of the database, when AFS ranged from 65% to 75%, to almost 80% for the last few years of the study, although this was not statistically significant. Preintervention factors associated with lower AFS at multivariate analysis included diabetes ( P = .002), increasing age ( P < .001), short-duration ischemia ( P = .027), Fontaine grade ( P = .001), and ischemia with neurosensory deficit ( P = .004). AFS was improved in patients receiving warfarin sodium at the time of the arterial occlusion ( P = .04). Mortality was higher in women ( P = .006) and in older patients ( P < .001), and in patients with native vessel occlusion ( P < .001), emboli ( P = .02), or a history of ischemic heart disease ( P < .001). Amputation risk was greatest in younger men ( P < .001) and in patients with more severe ischemia ( P = .02), graft occlusion ( P < .001), or native vessel thrombotic occlusion ( P = .02). Conclusion Experienced surgeons and radiologists can achieve an AFS of about 80% in selected patients with acute leg ischemia. Information from the NATALI database can be used in selection of an appropriate intervention in the individual patient.

Homologous vein transplantation in cruropedal arterial reconstruction

Allogenic venous transplantation represents an alternative procedure for preventing leg amputation. This study reviewed the question of whether immunologic monitoring and immunosuppressive therapy provide results close to those of autologous reconstructions. Twenty-eight patients received 31 homologous venous transplants. The average age in this group of 15 women and 13 men was 64.5 years. Limbs in danger of amputation could be kept longer in two thirds of them. These promising results show the superiority of this method over the use of alloplastic material in regions with cruropedal vessels. Therefore, it can be recommended in acute leg ischemia with lack of autologous vascularity. Improving guidelines for indication will be an interesting research field, and more contributions are needed.

Acute Leg Ischaemia from Aortic Occlusion due to Tension Pneumoperitoneum

In this paper, an unusual case of acute leg ischaemia originating from compression by a high pressure pneumoperitoneum is described.

A comparison of 50 initial endoluminal endograft repairs for abdominal aortic aneurysm with 50 concurrent open repairs

Purpose To review the results of our initial experience with endovascular repair of abdominal aortic aneurysm (AAA) with respect to morbidity and mortality and to compare these outcomes with those of transabdominal repair. Methods We reviewed the first 50 consecutive endovascular AAA repairs performed at our institution from November 1999 to January 2002. Pre-operative risk factors, intraoperative variables and post-operative outcomes were assessed. All endovascular patients were followed with periodic examination, contrast-enhanced computed tomography and/or duplex scanning. Comparison was made to 50 patients undergoing standard open repair over a similar time period. Results Fifty patients underwent endovascular AAA repair (mean age 72.5, AAA size 5.5 cm). Endovascular devices employed were manufactured by Ancure (Guidant Corp.), and AneuRx (Medtronic). Preoperative risk factors were similar to patients undergoing transabdominal repair. Mean operative time was 169 minutes and estimated blood loss was 450cc with average blood replacement of .18 units. Median ICU stay was 0 days and mean hospital stay was 2.3 nights. There were no conversions to open repair, however there was one aborted endovascular attempt. Morbidity included MI (2%), colon ischemia (1%), acute renal insufficiency (4%) and leg ischemia (4%). There was one death within 30 days. Seven endoleaks were identified (6 type II and 1 type I) and were managed angiographically. Conclusions The short-term surgical morbidity and mortality rates for endovascular repair of AAA are acceptably low and are comparable to the transabdominal approach.

Management of acute leg ischaemia in the elderly.

Peripheral thrombolysis is advocated by some as the best initial treatment for acute leg ischaemia; but this may not be true for elderly patients. This study reviewed the management of acute leg ischaemia in patients aged over 75 years. Over a 5-year interval, 91 events of acute leg ischaemia in 84 patients were managed in a single district general hospital according to a local protocol. There were 60 women and 24 men of median age 81 (range 75-100) years. Fifteen patients were too elderly and infirm for active treatment and received anticoagulation alone. Some 76 events (84 per cent) occurred in patients suitable for active therapy: 33 were managed by initial surgery and 43 by peripheral thrombolysis with tissue plasminogen activator. Overall outcome after 30 days was limb salvage in 48 (53 per cent), amputation in five (5 per cent) and death in 38 (42 per cent). In actively treated patients the corresponding values were 43 (57 per cent), four (5 per cent) and 29 (38 per cent). Initial successful revascularization was more likely following surgery (29 of 33 versus 25 of 43 events with thrombolysis, P < 0.01), but the 30-day outcome was similar in the actively treated groups owing to subsequent morbidity and mortality. A group of patients (mostly women) with emboli could be identified, using clinical criteria, who had a high chance of successful revascularization following embolectomy. Late outcome remained poor due to associated co-morbid conditions. Thrombolysis is associated with substantial risk in the elderly, and with high complication rates.

Popliteal artery entrapment syndrome: collaborative experience of the Joint Vascular Research Group.

Popliteal artery entrapment syndrome (PAES) is rare and probably underdiagnosed. This study reviewed a collected experience. Patients were identified by the Joint Vascular Research Group (vascular surgeons from ten hospitals serving a population of approximately four million) during 1984-1995. Case notes were reviewed. Twenty-one legs in 17 patients were identified with PAES. There were 15 men and two women. The median age at presentation was 29 (range 14-45) years. One patient was excluded because no further information was available. PAES was bilateral in four patients in whom three legs were asymptomatic. At presentation, the duration of symptoms ranged from a few hours (acute leg ischaemia) to intermittent claudication of 6 years' duration. Primary investigation included angiography (20 patients), duplex imaging (four), plain radiography (one) and magnetic resonance imaging (one). In two cases, attempted thrombolysis failed. Surgery was carried out on 17 legs but failed in two. No amputations were required. Following surgery, 12 legs were asymptomatic and five had residual symptoms. PAES should be excluded in young patients with intermittent claudication or acute ischaemia.

Acute non-traumatic arm ischaemia.

Much attention has been paid to the management of acute leg ischaemia. Acute arm ischaemia is perceived as less of a problem because the risk of limb loss is lower. After conservative treatment up to half the patients have late symptoms, such as forearm claudication. This study was a review of all published English language data on acute arm ischaemia. The entire Medline database was searched and other references were derived from the material perused. There were no randomized or controlled studies. The incidence of acute arm ischaemia is one-fifth that of acute leg ischaemia. Patients with arm ischaemia tended to be older with a mean age of 74 years compared with 70 years for acute leg ischaemia. Since the development of the embolectomy catheter, embolectomy can be performed in most patients under local anaesthetic. Collected outcome included successful restoration of the circulation in 65-94 per cent of patients and amputation in 0-18 per cent. The mortality rate ranged from 0 to 19 per cent, despite the use of local anaesthesia, mostly from associated cardiac disease. Management by a vascular specialist may be beneficial, particularly in complex cases. An active approach to the management of acute arm ischaemia is safe and effective and reduces the risk of late disabling symptoms.

Current management of acute leg ischaemia: results of an audit by the Vascular Surgical Society of Great Britain and Ireland.

Management of acute leg ischaemia has changed in recent years. This study aimed to elucidate current practice throughout the UK and Ireland. Surgeons and audit departments were asked to return a questionnaire about every episode of acute leg ischaemia seen in the hospital between 1 January and 31 March 1996. A total of 539 episodes were reported in 474 patients (248 men) aged 19-96 (median 73) years. Common causes were thrombosis in situ (41 per cent), embolism (38 per cent) and graft or angioplasty occlusion (15 per cent). Vascular surgical advice was requested in 95 per cent of cases. Initial management was: immediate embolectomy in 21 per cent, anticoagulants in 13 per cent and no vascular intervention in 10 per cent. Arteriography was done in 56 per cent, followed by 186 endovascular and 165 surgical interventions. At 30 days, 70 per cent of limbs were definitely viable and 16 per cent had been amputated. The mortality rate was 22 per cent. Cases were reported by 86 of 182 hospitals contacted, but some referred no patients, and a supplementary audit of 54 cases (10 per cent size of the original sample) from non-contributing hospitals showed no important differences. Patients with acute leg ischaemia are generally treated by vascular specialists, with modern methods and acceptable results. This is being achieved despite insufficient vascular surgeons and radiologists for formal emergency rotas in most hospitals.

Mechanical Thrombectomy in Acute and Subacute Leg Ischemia

Mechanical Thrombectomy in Acute and Subacute Leg Ischemia

Bilateral Superficial Femoral Artery Aneurysms

True aneurysms of the superficial femoral artery (SFA) are a rare clinical condition. An unusual case, which contains true atherosclerotic aneurysms of the bilateral SFAs of which one is thrombosed and threatened the limb, is presented. Acute ischemia of the left leg following the thrombosis of the left SFA aneurysm was observed in the patient. A synthetic graft bypass between the common femoral and popliteal artery at its origin was performed following the ligation of the SFA and distal neck of the aneurysm.

Acute Leg Ischaemia from Thrombosed Popliteal Artery Aneurysms: Role of Preoperative Thrombolysis

Objective: to evaluate early and long term results of thrombolysis and surgery in acutely thrombosed popliteal artery aneurysms. Setting: retrospective study; teaching hospital. Materials: between 1990 and 2000, 109 popliteal artery aneurysms were operated on. In 24 patients acute leg ischaemia due to thrombosis of aneurysm was present. Methods: ten patients underwent urgent surgical intervention (group 1); and 14 thrombolysis with urokinase, until patency of popliteal and tibial vessels was achieved or for a maximum of 3 days (group 2). Ultrasonographic follow-up was performed at 1, 3, 6 and 12 months and then annually. Early results and follow-up data were analysed by chi-square test and life-table analysis (Kaplan–Meier curve) and late results were compared by mean of log rank test. Results: in group 1 early limb salvage was 70%; in group 2 it was 86% (p=n.s.). When thrombolysis was successful, patency and limb salvage were 100%. There was no local or systemic complications during thrombolysis nor worsening of ischaemia. Follow-up was completed in 91 cases, with a mean duration of 26 months. Forty-eight months primary patency rate was better, even if not statistically significant, in group 2 than in group 1. Conclusions: in patients with acute leg ischaemia due to thrombosis of popliteal artery aneurysms, preoperative thrombolysis can be considered a safe and effective alternative to urgent surgery.