Acute Limb Research Articles

Evaluation of Computerized Tomography Utilization in Comparison to Digital Subtraction Angiography in Patients with Peripheral Arterial Disease

ObjectivesPerform literature review to analyze current practices in imaging patient with peripheral arterial disease (PAD) and examine patterns in our practice in order to assess whether a lower extremity computed tomography angiography (CTA) in addition to digital subtraction angiography (DSA) enhanced the assessment of vessel calcification, percentage of stenosis; and affected outcomes in patients with peripheral arterial disease. Methods and MaterialsThe study included patients who underwent lower extremity imaging and were followed up to 12 months. This population was divided into cases who had both an angiogram and CTA performed within 30 days (n=20), and controls who underwent angiography only (n=19). Baseline characteristics, imaging results, and clinical outcomes were analyzed. ResultsThirty-nine patients met study criteria (mean age was 58.4 years, 69.2% were males, and 33.3% had diabetes). Patients mostly presented with tissue loss/rest pain (10.3%), claudication (15.4%), acute limb (10.3%), and trauma (15.4%). We have not observed any statistically significant differences in various examined blood vessels when their features (e.g. vessel diameter, stenosis, calcifications) were assessed by CTA combined with angiography versus angiography alone. The exceptions were external iliac artery, superficial femoral artery and dorsalis pedis vessels. In external iliac artery percentage of stenosis was 1.11% as determined by CT scan versus 30% by angiography (P=.009). For superficial femoral artery stenosis the percentage determined by CT was 48.68% versus 81.41% by angiography, and observed difference between two modalities was statistically significant (P=.025). For dorsalis pedis percentage of stenosis detected by CT scan was 60.63% versus 22.73% by angiography, and the differences in findings by these modalities were statistically significant (P=.039). The most frequent perioperative complication was cardiac-related (35.5%). Nineteen patients were readmitted and 8 had re-interventions within 12 months. ConclusionBoth imaging modalities yielded similar results for assessing vessel calcification and percentage of stenosis regardless of anatomic vessel location. Overall, utilization of CTA in addition to angiography for large vessels above the knee (e.g. iliac artery, superficial femoral artery) and below the knee for dorsalis pedis provided more detailed information on the properties of these vessels. Therefore, during pre-operative assessments, CTA may be helpful in addition to angiography for planning surgical and endovascular interventions for symptomatic PAD treatment in larger vessels.

A Phase II randomized controlled trial evaluated antithrombotic treatment with fesomersen in patients with kidney failure on hemodialysis

Patients with kidney failure on hemodialysis (KF-HD) are at high risk for both atherothrombotic events and bleeding. This Phase IIb study evaluated the dose-response of fesomersen, an inhibitor of hepatic Factor XI expression, versus placebo, for bleeding and atherothrombosis in patients with KF-HD. Patients were randomized to receive fesomersen 40, 80, or 120 mg once-monthly, or matching placebo, for up to 12 months. The primary safety endpoint was a composite of major bleeding and clinically relevant non-major bleeding (MB/CRNMB). Exploratory endpoints included post-dialysis arterio-venous (AV)-access bleeding, major atherothrombotic events (composite of fatal or non-fatal myocardial infarction, ischemic stroke, acute limb ischemia/major amputation, systemic embolism, symptomatic venous thromboembolism), AV-access thrombosis, and clotting of the hemodialysis circuit. Of 308 participants randomized, 307 received study treatment and were analyzed. Fesomersen led to a dose-dependent and sustained reduction of steady-state median FXI levels by 53.6% (40 mg group), 71.3% (80 mg group), 86.0% (120 mg group), versus 1.9% in the placebo group. MB/CRNMB events occurred in 6.5% (40 mg group), 5.1% (80 mg group), 3.9% (120 mg group), and in 4.0% of those receiving placebo (pooled fesomersen versus placebo P= 0.78). Major atherothrombotic events occurred in 1 patient (1.3%) in each treatment arm. MB/CRNMB bleeding and post-dialysis AV-access bleeding were not related to predicted FXI levels. Lower predicted FXI levels were associated with reductions in hemodialysis circuit clotting (P= 0.002) and AV-access thrombosis (P= 0.014). In patients with KF-HD, fesomersen produced a dose-dependent reduction in FXI levels associated with similar rates of major bleeding compared with placebo. REGISTRATION: URL: https://www.clinicaltrials.gov; unique identifier: NCT04534114.

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.

Surgical Specifics of Lower Limb Superficial Thrombophlebitis Combined with Undifferentiated Connective Tissue Disease

Background. Superficial thrombophlebitis of lower extremities is among the most frequent acute vascular pathologies. Concomitant undifferentiated connective tissue dysplasia exerts specific changes in its clinical course.Aim: A study of the specific dynamics of acute lower limb superficial thrombophlebitis (ST) and its surgical treatment in patients with undifferentiated connective tissue dysplasia (UCTD).Materials and methods. The case histories, surgery reports and follow-up examinations of patients treated at the Vascular Surgery Unit during 2012–2020 were analysed. A total of 86 patients had signs of UCTD and underwent classical crossectomy of the great saphenous vein (Troyanov operation).Results and discussion. Duplex ultrasound of lower limb veins in 34 (39.53 %) patients revealed a discrepancy between the upper localisation of thrombotic masses in the great saphenous lumen and the external boundary registered for clinical manifestations, hyperaemia and tissue thickening. In 69 (80.23 %) patients, four or more phenotypic UCTD markers were exposed. In 74 (86.05 %) cases, a classical Babcock phlebectomy was performed as a next stage within one year after an acute thrombophlebitis attack had subsided. Of 12 (13.95 %) patients not having had a second-stage phlebectomy within one year: 4 people had UCTD signs — they refused surgery due to absent significant complaints or marked saphenous reflux; 3 had a deep vein thrombosis episode; 5 had no saphenous reflux of lower extremities in ultrasound examination.Conclusion. The registration of phenotypic signs of undifferentiated connective tissue dysplasia is recommended in choosing a surgical tactic to treat acute ascending thrombophlebitis of lower limb saphenous veins.

Thromboembolectomy for acute lower limb ischemia: Contemporary outcomes of two surgical methods from a single tertiary center.

The current treatment of acute lower limb ischemia (ALLI) includes open surgical and percutaneous pharmaco-mechanical thromboembolectomy (TE). We hereby report our results with open surgical TE over a 10-year period and compare our outcomes using routine fluoroscopic assisted TE (FATE) with blind and selective on demand fluoroscopic-assisted TE (BSTE). This is a retrospective analysis of all patients who underwent open surgical TE for acute lower limb ischemia at a single tertiary center between 2008 and 2018. Patients were divided into a group who underwent BSTE and another who underwent routine FATE. Data on presentation, medical history, surgery performed, and short-term outcomes were retrieved from medical record. Comparison between baseline characteristics and outcomes of both groups were made using t-test and chi-square analysis. Over 10years, 108 patients underwent surgical TE. Thirty-day mortality rate and 30-day major lower extremity amputation rate in the cohort were 12.0% and 6.5%, respectively. On subgroup analysis, 53 patients were treated by BSTE and 55 patients by FATE. There was no significant difference in 30-day mortality rate (11.3% vs 12.7%, p-value = .82) and 30-day major amputation rate (9.4% vs 3.6%, p-value = .454) between the two groups. Local anesthesia was more frequently performed in patients undergoing FATE (58.2% vs 24.5%, p-value < .001). More than one arteriotomy was more frequently required in patients undergoing BSTE (2.6% vs 45.5%, p-value < .001). Patients with infrapopliteal involvement undergoing FATE required less further interventions such as patch angioplasty (2.6% vs 36.4%, p-value < .001) and bypass (2.6% vs 22.7%, p-value = .01). ALLI remains a disease of high morbidity and mortality. Open surgical TE offers an effective approach to treat ALLI. The addition of fluoroscopy to the conduction of TE could be associated with valuable benefits, especially in patients with infra-popliteal involvement. Randomized controlled trials are needed to objectively assess the therapeutic potential of FATE.

COVID-19 Related Acute Lower Limb Ischemia Treated Via Percutaneous Thrombectomy and Catheter Direct Thrombolisis

Background: The aim of this report is to describe and discuss a unique case of acute lower limb ischemia presented in a recovered COVID-19 patient treated via percutaneous mechanical thrombectomy and catheter directed thrombolysis. Starting from this singular case a wide literature review regarding COVID-19-related thrombo-embolic complications has been accomplished. Methods: A 47-year-old male was admitted to the emergency unit with acute lower limb ischemia three weeks after testing positive for COVID-19. He had been isolated at home because of minor COVID-19-related symptoms. Angio-CT-imaging showed a segmental occlusion of the common iliac artery coupled with retro-articular popliteal artery and leg vessels thrombosis. The patient was first unsuccessfully submitted to trans-femoral iliac thrombo-embolectomy. Results: Instead of peripheral limb vessel re-thromboembolectomy, a percutaneous mechanical thrombectomy coupled with leg vessel catheter direct thrombolysis was performed. The completion angiography showed the recanalization of the popliteal artery and leg vessels as far as the ankle but with a reduced forefoot vascularization. The fibrinolytic treatment was continued for 8 hours post-operatively. A compartment syndrome complicated the early post-operative course. There was a progressive recovery of ischemic symptoms and at 6-month follow-up, peripheral pulses were palpable with an almost complete normalization of foot and toe perfusion and motility. Conclusion: Acute lower limb ischemia following COVID-19-related arterial thrombo-embolic events represents a severe complication of COVID-19 infection and may result in a high rate of revascularization failure. In these cases, Percutaneous Mechanical thrombectomy coupled with catheter directed thrombolysis might represent a less traumatic and more selective approach.

A catastrophic seronegative anti-phospholipid syndrome: case and literature review

BackgroundAntiphospholipid Syndrome (APS) is a multisystemic autoimmune disease characterized by arterial and venous thrombosis and / or obstetric morbidity in the presence of at least one circulating anti-phospholipid antibody. The spectrum of vascular events varies from deep venous thrombosis to catastrophic APS, a rare form characterized by acute multiorgan thrombosis and high mortality.Case reportWe present the case of a 32-week pregnant woman arriving in the hospital emergency room with bilateral acute lower limb ischemia. In the obstetric evaluation, fetal death was declared. Computerized Tomography angiography showed pulmonary embolism of both pulmonary arteries, areas of splenic and right renal infarction and multiple arterial and venous thrombosis. The patient underwent urgent caesarean section and axillary-bifemoral bypass. No events registered. In the postoperative period, in an intensive care unit, treatment with rituximab and plasmapheresis were added to anticoagulant therapy. The laboratorial investigation was negative for thrombophilia and autoimmune diseases.ConclusionCatastrophic APS develops quickly, with multiorgan involvement and high mortality rate. The presented case poses a multidisciplinary challenge, with the surgical approach of extra-anatomical revascularization being less invasive and guaranteeing immediate perfusion of the lower limbs. Although the serological tests were negative for anti-phospholipid antibodies, this case hardly fits into another diagnosis. Therefore, it was treated as a catastrophic APS, having shown a favorable evolution.

Assessment of venous Doppler ultrasound findings of acute unilateral lower limb swelling in a tertiary facility in central Ghana: a retrospective analytical study

BackgroundUnilateral lower limb swelling has wide differential diagnoses with varying treatment plans, requiring an early and accurate diagnosis. Doppler ultrasound offers an extensive examination of the vascular system providing a platform for diagnosis and avoidance of unnecessary invasive procedures. Thus, it becomes pertinent to ensure that all the sonographic information required for the accurate diagnosis of a swollen lower limb is documented and critically analyzed in our setting, hence this study.ResultsThe records of a total of 151 patients with acute unilateral lower limb swelling were retrieved, females constituted the majority (51.7%). The overall mean age was 58.70 ± 16.71 years. Statistical significance was specified at p ≤ 0.05 for this study. The males were on the average 1.86 years younger than the female, but this difference was not statistically significant (p = 0.495). Patients older than 60 years constituted the majority 72 (47.7%) followed by the 40–60-year age category 61 (40.4%), and the left lower limb was affected more often 82 (54.3%). Multiple inguinal lymphadenopathy 82 (35.7%) and edema with thickened skin and subcutaneous layers 67 (29.1%) were the two most recurrent ultrasound features. There was no significant association between the sonographic features and the diagnoses made for acute unilateral lower limb swelling, except for the feature of edema with thickened skin and subcutaneous layers (p = 0.004) and the diagnosis of cellulitis (p = 0.047) that increased significantly with age.ConclusionMultiple inguinal lymphadenopathy and edema of the skin and subcutaneous layers were the most recurrent ultrasound features with cellulitis as the main diagnosis for acute unilateral lower limb swelling in our setting. Edema with thickened skin and subcutaneous layers and cellulitis both increased significantly with age. Sonographers, sonologists, and radiologists must be on the look-out for these in their practices.

EP.TU.192Phlegmasia cerulea dolens associated with lung abscess

Abstract Introduction Phelgmasia cerulea dolens (PCD) is a rare limb and life-threatening condition caused by extensive of deep veins thrombosis of the extremities and it is classically associated with extensive oedema, severe pain and skin mottling which may lead to compartment syndrome, venous gangrene, and death. Case presentation We present a rare case of phlegmasia cerulea dolens associated with lung abscess. A 40-year-old male with background history of right femoral vein thrombosis, cardiomyopathy with ejection fraction of only 10% presented with three days history of progressive swelling, pain and purple discoloration of right leg to the accident and emergency department at a district general hospital. He was treated with therapeutic low molecular weight heparin. He was found to have lung abscess 2 weeks after admission for which he was treated with broad spectrum intra venous antibiotics. In view of his poor ejection fraction, he was treated without any surgical intervention for PCD. Patient succumbed after 3 months of presentation. PCD is a rare vascular emergency condition if not recognized early and treated aggressively may lead to high morbidity and mortality. Conclusion Phlegmasia cerulea dolens is an acute limb and life-threatening condition. Early diagnosis and aggressive intervention with thrombolysis and thrombectomy is necessary to prevent morbidity and mortality.

Left ventricular unloading before percutaneous coronary intervention is associated with improved survival in patients with acute myocardial infarction complicated by cardiogenic shock

Abstract Background Left ventricular unloading with Impella before percutaneous coronary intervention (PCI) may improve survival outcomes in patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS). However, the optimal timing to initiate Impella remains controversial. Purpose We conducted a systematic review and meta-analysis to compare survival outcomes of patients supported with Impella before PCI (pre-PCI) with those supporte after (post-PCI). Methods This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 guidelines. Multiple databases were searched through March 2021. All studies evaluating the impact of pre-PCI versus post-PCI Impella placement in patients with AMI-CS were included. A composite primary endpoint included in-hospital, 30-day, and 6-month survival rates. Results We identified five observational studies comparing outcomes in 432 patients with AMI-CS, including 173 patients treated with Impella pre-PCI and 259 patients post-PCI. In the pooled analysis, patients in the pre-PCI group had significantly lower in-hospital mortality compared to patients in the post-PCI group (RR 0.62, 95% CI: 0.50–0.76, I2=0%). Reduced mortality rate in the pre-PCI group persisted through 30-days (HR 0.61, 95% CI: 0.47–0.80, I2=0%) and at 6-months (HR 0.67, 95% CI: 0.45–0.99, I2=0%). There was no difference in the risk of adverse events including re-infarction, stroke, major bleeding, acute ischemic limb, access site bleeding, and hemolysis. Conclusion In a meta-analysis of studies evaluating mortality among AMI-CS patients treated with primary versus bailout left ventricular support, Impella placement prior to PCI was associated with improved survival. Funding Acknowledgement Type of funding sources: None. Forest plot for mortality

An Unusual Cause of Acute Unilateral Limb Weakness with Altered Sensation in a Young Lady

This case reports an acute onset of unilateral weakness in a 28-year-old lady who was found collapsed on the floor, unconscious. Initial examination revealed a right-sided facial droop, arm and leg weakness and right leg drift. There was also a decreased sensation in her right forearm. She has no significant past medical history and is not on any regular medications. She was transferred to the nearest emergency department for an urgent stroke assessment. The first CT brain did not show any acute ischaemic or haemorrhagic infarct, but she proceeded to receive thrombolysis in view of her symptoms. Her blood workup was normal. The next day, she developed increased weakness of her right arm and leg. A repeat CT scan was performed to rule out a post-lysis bleed, which was negative. An MRI was later performed, and no other abnormalities were detected. She exhibited a positive Hoover’s sign in the right leg and a diagnosis of functional neurological disorder (FND) was made. This condition can be characterised by a motor and sensory dysfunction, and loss of consciousness. Its presentation can be chronic or acute. Although the prevalence of FND is not entirely known, it is thought to be the second most common reason for neurology outpatient appointments after migraine and headache. It is rarely seen in children and tends to affect more women than men. This case highlights the importance of acknowledging functional neurological disorder as a differential diagnosis of unilateral weakness to avoid further unnecessary investigations or interventions.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S7

A Case of Brachial Artery Thrombosis Caused by Massage of an Occluded Arteriovenous Graft

Background: Acute upper limb ischemia (AULI) is a potential complication associated with massages of occluded vascular accesses in patients undergoing hemodialysis. Pharmacological thrombolysis, endovascular intervention and surgical intervention are possible treatment options. Deciding the appropriate treatment strategy is still a controversial issue. Case Presentation: The patient was a 43-year-old woman with renal failure who underwent hemodialysis and peritoneal dialysis. She was found to have an arteriovenous graft (AVG) thrombosis at the start of a hemodialysis session. She underwent massage of the vascular access, and immediately after the massage, she reported pain and cyanosis in her right-hand fingers and was referred to our hospital. Duplex ultrasonography revealed a large number of thrombi in the brachial, radial and ulnar arteries. AULI due to brachial artery thrombosis was diagnosed and surgical intervention was performed on the same day. The vascular wall of the forearm artery was incised vertically against the running vessel and thrombi around the bifurcation of the radial and ulnar arteries were removed. Angiography guided-surgical intervention was performed and improvement in blood flow was achieved. The patient was discharged on the second day after the operation. Conclusion: Surgical intervention has been reported as an effective treatment of AULI due to brachial artery thrombosis after massage of an occluded vascular access.

Acute Upper Limb Ischemia: Prompt Surgery and Long-Term Anticoagulation Prevent Limb Loss and Debilitation.

BackgroundAcute upper limb ischemia is an uncommon clinical manifestation of thromboembolism seen predominantly in patients with atrial fibrillation. Treatment can be by conservative or surgical means but the consensus is that after conservative treatment, symptoms still persist. In this series, an attempt was made at limb preservation and return to functional capacity by early surgery in all patients diagnosed with acute limb ischemia.MethodsPatients referred with upper limb ischemia (22) were stratified into non-acute (6) treated with anticoagulation alone and those with acute ischemia. Sixteen (16) patients, age range 30–92 years (median 62.4 years) comprising mainly females (13), had clinical evidence of severe ischemia and underwent immediate brachial embolectomy with postoperative anticoagulation.ResultsSixteen patients underwent 20 embolectomies with immediate reperfusion of limbs and relief of symptoms. Two patients had two re-operations each due to recurrent symptoms but both recovered with good outcome, one going on to have an axillary-radial bypass. There was no limb disability nor limb loss, but one postoperative mortality. All other patients were seen at their 1-year review and at 5 years, eleven out of 15 patients were still alive with most resuming an active lifestyle and some returning to work.ConclusionGood outcomes were obtained in this series in both the short and long term. Despite one mortality, there was no limb loss nor disability in a mainly elderly population. Prompt surgery and meticulous long-term anticoagulation reduced complications and improved limb salvage rates ensuring that patients had a good quality of life after surgery.

Acute Lower Limb Ischemia during Covid 19 Infection, a Worrying Complication!

Admittedly, the respiratory picture remains the most classic, however, covid 19 is lately considered to be a vasculitis affecting several organs, and therefore which is the origin of other extra-pulmonary manifestations, in particular thromboembolic disease (both venous and arterial) which has increasingly become a dramatic complication to be feared during this pandemic, due to its negative impact on the prognosis of affected patients, increasing the need for a resuscitation environment and the death rate. The mechanism is multifactorial, associating endothelial damage, an abnormality of hemostasis, and immunothrobosis [1]. We report the case of a 52-year-old young patient who had an acute ischemia of his left lower limb, by embolization of a thrombus located in the left ventricle, during his involvement by covid 19 and who was taken in charge immediately. The interest of this observation is to shed light on this complication which often accompanies infection by covid 19, which has become, not only a respiratory disease, but also a vasculiritis with its significant risk of thromboembolism.

A Case of Idiopathic Thoracic Spinal Subdural Hematoma With Bilateral Lower Limb Paralysis

Subdural hemorrhage is rare and is mostly triggered non-traumatically due to intracranial surgery, lumbar puncture, anticoagulant therapy, blood diseases, vascular malformations, and tumors. We experienced a case of idiopathic subdural hematoma with acute bilateral lower limb paralysis on postoperative day 4 after laparoscopic hysteromyomectomy.The patient was a 40-year-old woman with uterine myoma who took no medication nor had history of trauma or abnormalities such as vascular malformations. Four days after laparoscopic surgery, sudden chest and back pain and bilateral lower limb paralysis appeared. Muscle weakness was found predominantly on the left side. In manual muscle test (MMT), the quadriceps femoris was 5/5 on both sides, but the tibialis anterior, extensor pollicis longus and flexor pollicis longus were 5/5 only on the right, and 2/5 on the left side. Warm pain sensation was decreased below Th4 (Fourth thoracic vertebra), and the right side showed a greater decrease of deep sensation than the left. Excretion was difficult and dysuria was also apparent. There were no abnormalities in blood biochemical tests or in the blood coagulation system. Using the results of diagnostic imaging, as preoperative diagnosis of the patient, spinal subdural hematoma was suspected. Conservative treatment was initially conducted but the emergency surgery for hematoma removal was performed at 14 hours after the onset because of progression of paralysis. This resulted in improvement of neurological symptoms including lower limb paralysis, bladder-rectal disorder and hypoesthesia.If subdural hematoma is suspected regardless of the cause, it is important to observe neurological findings over time and make a quick decision to treat with surgery.

Comparison of digital subtraction angiography combined arterial thrombectomy versus simple arterial thrombectomy in the treatment of acute lower limb ischemia

BackgroundThis study aimed to compare the clinical efficacy of digital subtraction angiography (DSA) combined arterial thrombectomy versus simple arterial thrombectomy in the treatment of acute lower limb ischemia (ALI).MethodsThis retrospective cohort study collected the clinical data from 124 patients (128 affected lower limbs) with ALI who underwent emergency surgery from March 2010 to November 2019. Patients were consecutively divided into Group A and Group B. Patients in Group A underwent simple arterial thrombectomy via the Fogarty catheterization. Patients in Group B underwent arterial thrombectomy, and the DSA was performed during the surgery. The differences in the success rate of primary surgery, the second intervention rate, and the amputation/mortality rate within 30-days after surgery were compared.ResultsIn Group A, 4 of 70 limbs (5.7%) were amputated, 54 of 70 limbs (77.1%) had improved blood flow, 14 of 70 limbs (20.0%) received a second intervention, and 3 of 68 patients (4.4%) died within 30 days. In Group B, 1 of 58 limbs (1.7%) was amputated, 56 of 58 limbs (96.6%) had improved blood flow, 3 of 58 limbs (5.2%) received a second intervention, and 2 of 56 patients (3.5%) died within 30-days. The success rate of primary surgery, the second intervention rate, and the amputation rate of Group B were significantly lower than Group A (P < 0.05).ConclusionArterial thrombectomy combined with DSA may effectively improve the clinical efficacy of patients with ALI.

Analysis of the effect of high-quality nursing in the application of acute lower limb arterial embolization.

Analysis of the effect of high-quality nursing in the application of acute lower limb arterial embolization.

The plasma D-dimer trends and their value in acute lower limb ischemia patients treated by catheter directed thrombolysis

To investigate the change trends of plasma D-dimer during catheter-directed thrombolysis (CDT) in acute lower limb ischemia (ALI) patients and their clinical value. A retrospective review of patients with ALI who received CDT was carried out. The repeated measurements of plasma D-dimer were analyzed by generalized estimating equations (GEEs) and the change trends of D-dimer were analyzed by spline regression approach. A total of 150 patients were included. Among them, 3 days of CDT was ineffective in 41 cases, effective in 33 cases and markedly effective in 76 cases. The results of GEEs analysis showed that serum D-dimer changed significantly with time (time effect, P < 0.001). Serum D-dimer levels of patients with different treatment outcomes were different after treatment (group effect, P < 0.001), and serum D-dimer levels in these three groups showed different trends over time (group*time effect, P < 0.001). The different trends in serum D-dimer level with time after treatment in the three groups could be directly seen in the spline regression curve (P < 0.001). The plasma D-dimer changes regularly during CDT for ALI. We can predict the efficacy of CDT and guide adjustments of the therapeutic regimen according to the trend of D-dimer changes during thrombolysis.

Complex endovascular repair of type B aortic dissection and predicting left arm ischemia: a case report

BackgroundThoracic endovascular aortic repair (TEVAR) is the gold standard for surgical management of descending thoracic aortic pathology. Depending on the anatomy, TEVAR often requires deployment across the origin of the left subclavian artery (LSA) to obtain a proximal seal, thus potentially compromising perfusion to the left upper extremity (LUE). However, in most patients this is generally well tolerated without revascularization due to collateralization from the left vertebral artery (LVA).Case presentationWe present a complex 59-year-old Caucasian patient case of TEVAR with a history of prior arch debranching and intraoperative LSA coverage requiring subsequent LSA embolization and emergency take-back for left carotid–subclavian bypass.ConclusionThe purpose of this case report is to highlight an often overlooked anatomic LVA variant and an atypical, delayed presentation of acute LUE limb ischemia.

Idiopathic spontaneous compartment syndrome of the right lower limb: a case report

BackgroundAcutely painful lower limb is a common presentation to the emergency department, and acute compartment syndrome is an important differential diagnosis to consider given the correct predisposing history and clinical presentation. However, idiopathic spontaneous compartment syndrome is an uncommon occurrence.Case presentationA 54-year-old Caucasian man with no previous comorbidities presented with acute right-sided lower limb pain with classical symptoms showing gradual evolution. He had no other history of medical relevance and no preceding injury. Examination showed a marginally enlarged right lower limb with stretched skin and tenderness. Routine blood tests were normal including D-dimer levels. However, in the absence of any underlying risk factors, acute compartment syndrome was suspected on clinical merit and confirmed with magnetic resonance imaging. He underwent successful surgical intervention with fasciotomy and achieved good recovery.DiscussionAcute compartment syndrome, though commonly attributed to trauma, can occur due to varied causes. Spontaneous acute compartment syndrome is attributed to diabetes mellitus. Idiopathic acute spontaneous compartment syndrome occurs in the absence of either intrinsic or extrinsic risk factors and is rarely documented in the literature. This case highlights the importance of appreciating classical clinical signs and having the clinical acumen to consider an obvious diagnosis even in its rarer form of presentation.