Acute Lower Extremity Ischemia Research Articles

Pounce Thrombectomy System to Treat Acute and Chronic Peripheral Arterial Occlusions

Peripheral arterial occlusions are composed of variable amounts of thrombus. Endovascular techniques should initially address the variably aged thrombus prior to treating plaque (balloon angioplasty (PTA) +/- stenting). This should ideally be accomplished in a single procedural session. Forty-four consecutive patients treated with the Pounce thrombectomy system (PTS) as captured in a retrospective database who presented with acute (n=18), subacute (n=7), or chronic (n=19) lower extremity ischemia were treated and followed for a mean of 7 months. The peripheral occlusions were considered thrombus-dominant by the feel and ease of wire traversal. They were treated with PTS along with complimentary PTA/stenting when appropriate. The mean number of passes with PTS was 4.0 +/- 2.7. Sixty-five percent (29/44) were successfully revascularized in a single setting with only 2 requiring concomitant thrombolysis for incomplete thrombus removal from the PTS target artery. An additional fifteen patients (34%) had thrombolysis for tibial thrombus that was not attempted with PTS. PTA +/- stenting after PTS occurred in 57% of limbs. Technical success was 83% and procedural success was 95%. Reintervention rate throughout follow-up was 22.7%. Major amputation occurred in 4.5%. Complications were limited to minor groin hematomas (n=3). Outcomes were equally effective in patients with pre-existing stents or de-novo arterial occlusions as evidenced with ankle brachial index improvement from 0.48 pre- to 0.93 post-intervention and 0.95 at latest follow-up (p<0.001). PTS coupled with PTA/stenting is expeditiously safe and effective in patients with thrombus-associated lower limb occlusion.

Age is Associated With Increased Mortality but Not Other Complications in Patients Undergoing Catheter-directed Arterial Thrombolysis for Acute Lower Extremity Ischemia

Catheter-directed arterial thrombolysis (CDAT) has become a mainstay for the treatment of acute lower extremity ischemia (ALI). Although CDAT can be effective therapy, its use in older patients (>80 years) is considered a relative contraindication due to concern for complications. We evaluated short-term clinical outcomes of patients undergoing CDAT for ALI stratified by age. Patients with ALI undergoing CDAT between 2011 and 2021 were identified using the TriNetX Analytics Network, a federated network of nationwide health care organizations that provides de-identified patient data. The cohort was stratified by age (40-59, 60-79, and 80+ years) and analyzed by those receiving post-procedural tPA infusion and those not (itPA+ or itPA−). Outcomes included mortality, myocardial infarction (MI), amputation, acute blood loss, and reintervention. One-year outcomes were analyzed after propensity matching for demographics, comorbidities, and medications. After 1:1 propensity matching, there were significantly higher rates of mortality in the 60 to 79/itPA− group compared with the 40 to 59/itPA− group (8.7% vs 4.5%; P = .0020) and significantly higher rates of amputation in the 40 to 59/itPA− group compared with the 60 to 79/itPA− group (27.5% vs 22.6%; P = .0425). There were significantly higher rates of mortality in the 80+ group compared with the 40 to 59 group when stratifying in both itPA− (17.3% vs 4.1%; P < .0001) and itPA+ patients (18.0% vs 7.8%; P = .0153). There were also significantly higher rates of mortality in the 80+ group compared with the 60 to 79 group when stratifying in both itPA− (19.5% vs 9.0%; P < .0001) and itPA+ patients (16.7% vs 8.0%; P = .0043). Amputation rates in the 80+/itPA+ group were significantly higher compared with the 60 to 79/itPA+ group (28.1% vs 20.2%; P = .0488); there were similar rates of amputation in the 60 to 79/itPA− and 80+/itPA− groups. In patients undergoing CDAT for ALI there were higher rates of 1-year mortality in the 80+ patient group regardless of itPA status. Although there were significantly higher rates of 1-year mortality in 60 to 79/itPA− patients compared with 40 to 59/itPA− patients, mortality rates were similar in itPA+ patients. Complication rates were similar across all groups regardless of itPA status, apart from significantly higher 1-year amputation rates in 80+/itPA+ patients compared with 60 to 79/itPA+ patients. Older age is associated with increased mortality rates in patients undergoing CDAT for ALI. We found no association between increasing age and other postoperative complications.

Outcomes of Patients Admitted With COVID-19 Requiring Lower Extremity Interventions

The incidence and outcomes of patients with associated acute lower extremity ischemia (ALI) admitted with COVID-19 undergoing intervention is not clearly defined in the real-world population. Patients admitted with COVID-19 undergoing lower extremity (LE) procedures (open [OPEN] and endovascular [ENDO]) were evaluated regarding procedure types, demographics, and COVID-19 disease severity and outcomes. A retrospective study of a COVID-19 cohort in the Cerner Real-World Data, was queried from December 2019 to 2021. Included were LE procedures during inpatient COVID admission, disease severity using International Classification of Diseases, Tenth Edition (ICD-10) disease and procedure codes (admitted with COVID, COVID pneumonia [COVID-PNA], and severe COVID requiring mechanical ventilation [COVID-SD]), and outcomes including amputation and mortality. A total of 1,877,151 patients admitted with COVID were evaluated (1,342,708 admitted with COVID, 416,900 with COVID-PNA, and 117,543 with COVID-SD). Average age was 51.8 years, with men (45.0%), women (55.0%), Whites (70.0%), and Blacks (11.7%). Stratified by COVID severity, the incidence of COVID patients requiring LE procedures was 0.68% for COVID, 0.52% for COVID-PNA, and greater for COVID-SD 1.44% (P < .0001). A total of 6986 OPEN and 6032 ENDO LE procedures were performed (53.7% vs 46.3%; P < .0001). Overall mortality was 13.8% ENDO vs 11.5% OPEN (P < .05). Of those undergoing procedures, 61.4% were men vs 38.6% women (P < .0001). Following LE procedures, overall amputations occurred in 15.8% with no difference between OPEN and ENDO procedures (16.1% vs 15.4%; P = .3) or gender (men 16% vs women 15.3%; P = .3), but race was significantly different (Black 22.7% vs White 14.1%; P < .0001). Amputation rates significantly increased by COVID severity for ENDO (COVID 14.17% vs 20.5% COVID-SD; P < .0001) and OPEN (COVID 13.80% vs COVID-SD 23.01%; P < .0001). Overall mortality significantly increased for patients with COVID-SD (P < .0001). Although thrombotic events are increased with COVID, the number of patients requiring an LE intervention after hospitalization with COVID is low. Patients more often underwent OPEN procedures and were men. OPEN and ENDO procedures had similar amputation rates but were significantly higher for Black patients. Increased COVID severity was associated with significantly higher numbers of LE procedures performed, mortality rates, and amputations. Interestingly, gender did not influence outcomes following LE procedures in patients with COVID. These data may influence development of algorithms for treatment of COVID-associated ALI favoring endovascular therapies over open surgery and consideration of primary amputation over revascularization in patients with severe COVID.

Single-center Experience with JETi Hydrodynamic Thrombectomy System for Arterial Occlusions of the Extremities

Percutaneous aspiration thrombectomy is a new modality for treating patients with acute limb ischemia (ALI). We report our experience and outcomes using the JETi hydrodynamic thrombectomy system (Abbott Vascular, Abbott Park, IL) to treat acute arterial occlusions of the extremities. This a single-center retrospective review of patients with acute occlusions of peripheral arteries or grafts treated with the JETi from September 2020 to December 2022. JETi was used either as primary intervention or as an adjunct to treat distal vessel thrombus after proximal open thrombectomy. The primary outcome for success was defined as >50% luminal opening post-intervention. Indications, limb salvage, and major adverse events were reviewed. The JETi was used in 59 procedures (56 acute lower extremity ischemia [ALEI], three acute upper extremity ischemia [AUEI]) to treat 124 arteries in 57 patients. Mean age was 62 years (range, 29-95 years), and 49% were male. The mean duration of symptoms before hospitalization was 4.8 days (range, 0 hours to 21 days) for ALEI. The primary outcome was achieved in 102 of 124 (83%) arteries by JETi alone. Additional modalities including open thrombectomy, angioplasty, and stenting were used in five arteries to achieve the primary outcome. Seventeen arteries failed to achieve primary outcome with JETi with or without an adjunct. Reasons for failure were attributed to small artery size and chronic nature of the clot. Complete luminal patency with JETi thrombectomy alone was achieved in 52 arteries (42%). Additionally, 55 arteries underwent additional procedures (angioplasty and stenting) to restore complete luminal patency, which was successfully achieved in 49 vessels (89%) (Table). Average estimated blood loss in JETi-only procedures was 335 mL and 384 mL in those who underwent adjunctive procedures to achieve the primary outcome. Complications included distal embolization (5), access site hematoma (3), and acute kidney injury (AKI) (8). Two AKIs were attributed to rhabdomyolysis with creatine phosphokinas >10,000 IU/L; none of whom needed dialysis. There was a single 30-day mortality. Six patients required major limb amputations within 30 days – two after unsuccessful recanalization and one each for severe gangrene despite restoration of in-line flow, reocclusion of a distal bypass graft, recurrent ALEI postoperative day 15 with non-viable muscle on exploration, and a delayed compartment syndrome diagnosis. Success of the JETi to remove the targeted clot was 83%. The JETi system is an efficacious and safe tool for use in the treatment of acute artery occlusion.TableJETi thromboembolectomy technical success outcomes by vessel/graft intervened uponName of artery/graftNo. of each vesselJETi >50%JETi + adjunctive >50%JETi 100%JETI + adjunctive 100%JETI 4- adjunctive 50% <X <100%Aorta000000Common iliac660150External iliac642150Common femoral440310Superficial femoralI8170313IProfunda iroris220100Popliteal20I80882Anterior tibial16111840Tibioperoneal trunk13110821Peroneal artery13100910Posterior tibial1382631Femoral-anterior tibial bypass330030Femoral-popliteal bypass55004lAxillary femoral bvpass110100Axillary200000Subclavian110100Brachial110100124101552496 Open table in a new tab

Fasciotomy in the treatment of acute lower extremity ischemia due to trauma, vascular wounds at Viet Duc University Hospital

Objective: The predominant groups of fasciotomy in the treatment of acute lower extremity ischemia due to trauma, vascular wounds at Viet Duc University Hospital. Methods: A retrospective, descriptive, non-control study on patients with a diagnosis of acute lower extremity ischemia who underwent revascularization with leg fasciotomy at Viet Duc University Hospital in the period from January 2020 to December 2021. Results: In 70 studied patients, the male/female ratio = 1.8/1; mean age was 33.2 ± 13.2 years old. Vessels damaged by trauma accounted for 94.3%, wounds accounted for 5.7%; mainly popliteal artery accounted for 88.6%. 75.7% of patients had associated lower extremity fractures or dislocations. Rutherford acute limb ischemia grade IIa or higher accounts for 95.7%. 100% of patients were revascularized at &gt;6 hours from the time of the accident. All patients were able to open the leg fascia right at the beginning; 74.3% performed by a team of orthopedic surgeons; 98.6% of leg fasciotomies were 2 incisions for 4 compartments. The average time of fasciotomy’s closure was 13.84 ± 6.445 days, the earliest was 4 days, the latest was 31 days. After 1 month of discharge, 82.4% of patients limited movement of the limbs; 48.5% of patients did not feel pain in the extremities after surgery. After 6 months, 33.8% of the patients had limited limb movement, 97.1% did not feel pain in the extremities. Conclusion: Leg fasciotomy in the treatment of acute lower extremity ischemia due to trauma or injury is performed, in which, the duration of limb ischemia &gt; 6 hours, popliteal artery injury and the acute limb ischemia classification according to Rutherford from IIa are the predominant groups.

Comparison of Limb Salvage Rate in Early Versus Delayed Presented Patients of Acute Lower Limb Ischemia Undergoing Revascularization

Objective: To compare the limb salvage rate in early versus delayed presented patients of Rutherford Class IIB acute lower extremity ischemia undergoing revascularization.&#x0D; Study Design: Comparative prospective study&#x0D; Place and duration: Hayat Wali Medical Center, Rawalpindi Pakistan, from Apr 2019 to Mar 2020.&#x0D; Methodology: This study enrolled 42 patients, aged 20 to 70 years, with Rutherford Class IIB acute lower limb ischemia, which was divided into two groups. Group-I (delayed presented &gt;6 hours) consist of 30 patients, and Group-II (early presented &lt;6 hours) consist of 12 patients. All patients underwent embolectomy. The limb salvage rate was examined in the third postoperative month.&#x0D; Results: In Group-I, limb salvage was found in 18(60%) patients, while in Group-II, there were 11(91.67%) patients; a significant difference was observed between both groups (p-value &lt;0.05). The mortality rate was high in Group-I (delayed presented) as compared to Group-II (16.67% vs 0%) with a p-value &lt;0.05.&#x0D; Conclusion: The limb salvage rate was higher in early presented patients than delayed presented patients. Mortality and amputation rates were observed to be higher in delayed-presented patients.

Investigation of the Effects of Stress Hyperglycemia Ratio and Preoperative Computed Tomographic Angiography on the Occurrence of Acute Kidney Injury in Diabetic Patients following Surgical Thromboembolectomy.

Acute lower extremity ischemia (ALI) is a cardiovascular emergency resulting from embolic and thrombotic causes. Although endovascular techniques have advanced, surgical thromboembolectomy is still the gold standard. Emergency thromboembolectomy surgery involves an ischemia-reperfusion injury, which also poses a risk for acute renal injury (AKI). The stress hyperglycemia rate (SHR) has recently emerged as an important prognostic value in emergency cardiovascular events. In the present study, we aimed to analyze the impact of preoperative contrast-enhanced tomographic angiography (CTA) and the SHR value on postoperative AKI in emergency thromboembolectomy procedures in patients with insulin-dependent diabetes mellitus (DM). In this retrospective analysis, patients with DM who received emergency surgical thromboembolectomy after being hospitalized at our hospital with ALI between 20 October 2015, and 10 September 2022, were included. Patients were classified into two groups: Group 1 (N = 159), who did not develop AKI, and Group 2 (N = 45), who did. The 45 patients in Group 2 and the 159 patients in Group 1 had median ages of 59 (39-90) and 66 (37-93), respectively (p = 0.008). The percentage of patients in Group 2 with Rutherford class IIB and admission times longer than 6 h was higher (p = 0.003, p = 0.027, respectively). To determine the variables affecting AKI after surgical embolectomy procedures, multivariate logistic regression analysis was used. In multivariate analysis Model 1, age > 65 years (odds ratio [OR]: 1.425, 95% confidence interval [CI]: 1.230-1.980, p < 0.001), preoperative high creatinine (OR: 4.194, 95% CI: 2.890-6.156, p = 0.003), and Rutherford class (OR: 0.874, 95% CI: 0.692-0.990, p = 0.036) were determined as independent predictors for AKI. In Model 2, age > 65 years (OR: 1.224 CI: 1.090-1.679, p = 0.014), preoperative high creatinine (OR: 3.975, 95% CI: 2.660-5.486, p = 0.007), and SHR (OR: 2.142, CI: 1.134-3.968, p = 0.003), were determined as independent predictors for amputation. In conclusion, when an emergency thromboembolectomy operation is planned in insulin-dependent DM patients, renal risky groups can be identified, and renal protective measures can be taken. In addition, to reduce the renal risk, according to the suitability of the clinical conditions of the patients, the decision to perform a CTA with contrast can be taken by looking at the SHR value.

Predictors of poor outcomes after lower extremity revascularization for acute limb ischemia.

Acute lower extremity ischemia is one of the most common emergencies in vascular surgery and is a cause of considerable morbidity and mortality. The goal of this study was to evaluate outcomes of revascularization for acute lower extremity ischemia and to determine factors associated with perioperative morbidity and mortality. A total of 354 patients underwent urgent revascularization for acute lower extremity ischemia at an academic medical center between 2014 and 2019. A retrospective review of patients' demographics, comorbidities, etiology and severity of limb ischemia, and procedural characteristics was recorded. Outcomes, including postoperative complications, perioperative limb loss, and mortality, were analyzed. The mean patient age was 69 ± 17years, and 52% were females. 50% of patients presented with Rutherford Class IIb ischemia. Arterial embolization was the most common cause of limb ischemia, seen in 33% of cases. Open surgical revascularization was performed in 241 (68%) patients, while endovascular and hybrid approaches were utilized in 53 (15%) and 60 (17%) cases, respectively. Postoperative adverse events occurred in 44% of patients, including wound complications (11%), cardiac (5%) and pulmonary (16%) complications, strokes (4%), UTIs (10%), renal failure (14%), bleeding (5%), and compartment syndrome (3%). The rate of unplanned return to the operating room was 21%. Major adverse cardiovascular events were seen in 103 (29%) patients and major adverse limb events were seen in 57 (16%) patients. The median length of stay was 10 days (IQR = 4); 49% patients were discharged to skilled nursing facility and 19% were readmitted within 30 days.The rate of amputation during index admission was 10%, and perioperative mortality was 20%. Gender, tibial runoff, and etiology of limb ischemia were independent predictors of limb loss. Women had lower risk of limb loss than men (OR, 0.11; 95% CI, 0.023, 0.38). Poor tibial runoff (one-vessel or absence of flow below the knee) was a significant predictor of limb loss as compared to three-vessel runoff (OR, 14.92; 95% CI, 1.92, 115.88). Aneurysmal disease (OR, 38.35; 95% CI, 3.54, 42.45) and traumatic injuries (OR, 108.08; 95% CI, 8.21, 159.06) were the strongest predictors of amputation as compared to other etiologies of limb ischemia. Multivariate model identified ESRD (OR, 9.2; 95% CI, 1.8-46.3), degree of ischemia (class IIb or higher vs class IIa; OR, 3.5; 95% CI, 1.2-10.6), and age (OR, 1.5; 95% CI 1.1-2.0 for every 10years) as independent predictors of perioperative mortality. Urgent revascularization for management of acute limb ischemia is associated with high morbidity and mortality. Elderly patients with ESRD presenting with severely threatened limbs have especially high risk of perioperative mortality and may not be ideal candidates for limb salvage.

Factors Associated with Therapeutic Outcomes in the Treatment of Nontraumatic Acute Upper Limb Ischemia at a Tertiary Care Center in South India: A Prospective Analysis

Abstract Background: The outcomes of acute upper extremity ischemia (AUEI) demonstrated lower rates of limb loss (0%–3.1%) and mortality (~6%) compared to acute lower extremity ischemia. However, AUEI still is a challenge for a vascular surgeon as delays in diagnosis and treatment are likely to result in severe functional disability, even in the absence of overt tissue loss. Objectives: The objectives of this study are to determine the association of factors affecting the clinical outcomes of acute upper limb ischemia treatment. Methodology: A single-center prospective observational study was done between July 2021 and July 2023 on patients with AUEI who came to our emergency medicine department at a tertiary care center in South India. The demography, risk factors, duration of ischemia, time from onset of complaints, and primary intervention chosen were recorded. Functional improvement on subsequent follow-up intervals was analyzed to describe the surgical outcome. Results: Of 53 patients with AUEI, 31 (58.5%) had atrial fibrillation. In 81.1% of patients, thrombosis was the primary cause of acute limb ischemia. Most patients belonged to the 2A Rutherford classification (47.2%), followed by 2B (26.4%). Regardless of the severity of ischemia, the patients (n = 10) who arrived after 36 h had a higher rate of amputation (5; 50%). Lower levels of preoperative serum lactate dehydrogenase and serum glutamic-oxaloacetic transaminase were associated with better postoperative outcomes (P = 0.007) and lesser amputation rates (P = 0.017). Lower grades of ischemia, prompt intervention, and early consultation were all linked to better postoperative functional outcomes (P = 0.026). Conclusion: At our facility, AUEI due to cardiac or noncardiac emboli, thrombosis, or both was a significant cause of inhospital morbidity. An important risk factor for worse outcomes was hypertension. The availability of appropriate interventional care, and the timing of presentation after the onset of symptoms are thus significant modifiable factors in lowering the rates of amputation.

Results of thrombectomy in lower-extremity ischemia in patients with COVID-19 and respiratory failure of different severity

Aim. To analyze the results of thrombectomy in lower-extremity ischemia in patients with coronavirus disease 2019 (COVID-19) and respiratory failure of different severity.Material and methods. This retrospective, cohort, comparative study for the period from May 1, 2020 to March 1, 2022 included 305 patients with acute lower-extremity ischemia and COVID-19. Depending on the type of oxygen support, three groups of patients were formed: group 1 (n=168) — nasal oxygen insufflation; group 2 (n=92) — non-invasive ventilation (NIV); group 3 (n=45) — artificial ventilation (AV). Thrombectomy was carried out according to the standard technique using Fogarty catheters (3F-6F — depending on the vessel size). After the diagnosis was established before and after the start of surgical treatment, all patients received the following therapy: Unfractionated IV heparin infusion at an initial rate of 1000 U/r, adjusted to maintain the activated partial thromboplastin time at 2-3 times the normal value; 2. Oral acetylsalicylic acid 125 mg; 3. Analgesics.Results. Myocardial infarction and ischemic stroke were not detected in the total sample. The highest number of deaths (group 1: 5,3%, n=9; group 2: 72,8%, n=67; group 3: 100%, n=45; p&lt;0,0001), retrombosis (group 1 : 18,4%, n=31; group 2: 69,5%, n=64; group 3: 91,1%, n=41; p&lt;0,0001) and limb amputations (group 1: 9,5%, n=16; group 2: 56,5%, n=52; group 3: 91,1%, n=41; p&lt;0,0001) was recorded in group 3 patients.Conclusion. In patients receiving mechanical ventilation, COVID-19 have more aggressive course, which is expressed in an increase in laboratory para- meters (C-reactive protein, ferritin, interleukin-6, D-dimer), the severity of pneumonia and location of thrombosis in the tibial arteries. Among patients with COVID-19 receiving mechanical ventilation, the greatest number of rethromboses (91,1%), limb amputations (91,1%), and deaths (100%) are noted, which suggests the expediency of abandoning open thrombectomy in favor of anticoagulant/antiplatelet therapy in this cohort of patients. The development of arterial thrombosis in patients with COVID-19 receiving mechanical ventilation is an indicator of a high risk of death. Open thrombectomy in combination with anticoagulant/antiplatelet therapy is most effective in patients on nasal oxygen insufflation or NIV.

Early Versus Delayed Presented Patients with Acute Lower Limb Ischemia Undergoing Revasucularization: A Comparison of Limb Salvage Rate

Objective: To examine the success rate of limb salvage in patients with acute lower extremity ischemia of Rutherford class IIb who presented early vs late and were receiving revascularization Study Design: Comparative/observational study Place and Duration: This study was conducted in multi centers at Mardan Medical Complex and Teaching Hospital and DHQ Battagram during the period from January, 2021 to June, 2022 Methods: 60 patients with acute lower limb ischemia of Rutherford class IIB, ranging in age from 18 to 65, were recruited in this research. Two groups of patients were formed. 35 patients make up Group I (delayed presentation &gt;6 hours), while 25 patients make up Group II (early presentation 6 hours). Embolectomy was performed on each patient. At the third month following surgery, the limb salvage rate in the two groups was compared. P-value 0.05 was considered significant when the data were analyzed using SPSS 22.0. Results: Regarding age and gender, there was no discernible difference between the two groups (p-value &gt;0.05). A substantial difference was seen in the limb salvage rate between the two groups (p-value 0.05), with group I having 22 (62.9%) patients with limb salvage and group II having 21 (84%) patients with limb salvage. When compared to group II, mortality was higher in group I (delayed presentation) (17.1% Vs 0%) with a p-value &lt;0.05. Conclusion: The limb salvage rate was found to be much higher in early-presented patients than in delayed-presented patients. Patients who were presented later than those who were presented earlier had substantially higher 30-day death rates and amputation rates. Keywords: Early Presented, Acute Lower Limb Ischemia, Late Presented, Limb Salvage, Revascularization

S2128 Rectal Ischemia in a Patient After EVAR and COVID-19

Introduction: Ischemic proctitis is a rare, but serious, source of GI bleeding as mortality rates approach 20-40%. Patients for which ischemia should be considered are those with previous surgery, older patients, and those with known peripheral arterial disease. Case Description/Methods: 80-year-old male with history of hyperlipidemia and hypertension presented to the hospital for shortness of breath secondary to COVID-19 pneumonia. His respiratory status continued to decline requiring mechanical ventilation and ICU admission. During his admission, he was found to have acute left lower extremity ischemia requiring stenting of his superficial femoral artery and abdominal endovascular aneurysm repair (EVAR). He was started on anticoagulation with heparin infusion. His hospital course was further complicated large volume maroon-colored stools concerning for lower GI bleed. Colonoscopy was performed at the bedside to further evaluate. In the rectum, there were circumferential ulcerations with inflammation and exudate, extending 10 cm from the anal verge. Biopsies were consistent with rectal ischemia. Unfortunately, soon after the patient developed worsening acidosis requiring CVVHD and increased requirement for pressor support. The family ultimately decided to pursue comfort care and the patient was palliatively extubated (Figure). Discussion: Rectal ischemia is rare as the rectum has blood supply from the inferior mesenteric and bilateral iliac arteries. In our patient, during EVAR graft repair, the IMA was occluded by a stent, the iliac arteries however, remained intact providing the middle rectal and pudendal artery as sources of collateral blood supply. It is hypothesized that a hypercoagulable state caused by COVID-19 infection coupled with ongoing hypotension in the setting of critical illness in our patient with significant peripheral arterial disease led to the low flow state in bilateral iliac arteries causing ischemic proctitis. Rectal ischemia must be considered early in patients because, while most cases of lower GI bleeding can be treated conservatively, rectal ischemia is an indication for prompt surgical intervention. Surgical intervention is required to remove necrotic bowel and potential sources of infection causing septic shock.Figure 1.: Circumferential rectal ischemia as seen by colonoscopy.

Solitaire™ Stent Thrombectomy System in the Treatment of Acute Lower-Limb Ischemia: Comparisons in Safety and Effectiveness with Conventional Catheter-Directed Thrombolysis Therapy.

Objective The study aimed to investigate the safety and efficacy of the Solitaire™ AB Stent System (ev3 Inc., Plymouth, MN, USA) for the treatment of acute lower extremity ischemia (ALLI) compared with conventional catheter-directed thrombolytic therapy. Methods Retrospective analysis of patients with ALLI treated in the Department of Interventional Radiology at the First Hospital of Nanjing from January 2017 to April 2020 divided into a conventional (CDT) group (n = 106) and a percutaneous mechanical thrombectomy (PMT) group (n = 55) according to the procedure. PMT was performed using the Solitaire™ AB stent system. The combined clinical outcomes of mortality, major amputation, recurrent ischemia, and major morbidity were compared between the two groups. Results Of the 161 patients, 128 (79.5%) did not have a composite clinical outcome after 12 months of follow-up, namely, 78 CDT patients and 50 PMT patients, with significant differences in composite clinical outcome (26.4% vs. 9.1%, P = 0.010) and mortality (19.8% vs. 7.3%, P = 0.037) between them. Thrombolytic drug dose (19.34 ± 5.93 vs. 13.55 ± 6.54 mg, P < 0.001) and length of hospital stay (8.29 ± 3.91 vs. 5.49 ± 1.18 days, P = 0.003) were significantly lower in the PMT group. Conclusion PMT with the Solitaire™ AB Stent System is safer and more effective in treating patients with Rutherford stage I-IIB ALLI, with the advantage of rapid opening of obstructed vessels, shorter thrombolysis time, reduced thrombolytic dose, and improved blood flow to the infrapopliteal vessels.

Investigation of the effect of acute to chronic glycemic ratio on major amputation development after surgical thromboembolectomy in patients with acute lower extremity ischemia.

Acute limb ischemia (ALI) is an emergency vascular pathology in which perfusion is disrupted in the lower extremity and threatens extremity viability. The admission blood glucose (ABG)/estimated average glucose (eAG) value has recently been shown as a prognostic marker in acute cardiovascular events. In this study, we aimed to investigate the predictive role of an ABG/eAG value in predicting development of early postoperative major amputation after emergency thromboembolectomy operations in patients presenting with ALI. Patients who admitted to our hospital with ALI between November 01, 2016 and September 01, 2021 and underwent surgical thromboembolectomy were retrospectively included in the study. Patients who did not undergo postoperative limb amputation were recorded as Group 1, and patients who underwent major amputation in the early postoperative period (in-hospital), were recorded as Group 2. The median age of the 226 patients included in Group 1 and 72 patients in Group 2 were 58 (34-86) years and 69 (33-91) years, respectively (p<0.001). In univariate analysis, in-hospital amputation was found to significantly correlate with age>70 years (odds ratio [OR]: 1.914, 95% confidence interval [CI]: 1.351-2.319, p<0.001), PAD (OR: 1.698, 95% CI: 1.270-1.992, p = 0.002 re-embolectomy (OR: 2.184, 95% CI: 1.663-3.085, p < 0.001), admission Rutherford class (OR: 0.762, 95% CI: 0.591-0.859, p = 0.032), admission time>6 h (OR: 1.770, 95% CI: 1.480-1.152, p = 0.009), ABG (OR: 1.275, 95% CI: 1.050-1.790, p < 0.001), and ABG/eAG (OR: 1.669, 95% CI: 1.315-2.239, p < 0.001). According to our study, we can predict patient groups with a high risk of major amputation with the ABG/eAG value calculated from the blood values of the patients at the time of admission.

Open Repair Versus Endovascular Repair in the Treatment of Symptomatic Popliteal Artery Aneurysms

Endovascular and open surgical modalities are currently used to treat popliteal artery aneurysms (PAA). However, there is limited data on the comparative durability of both repairs to guide physicians especially in the treatment of patients presenting symptomatic. We aimed to study the comparative effectiveness of endovascular PAA repair (EPAR) versus open PAA repair (OPAR). The vascular quality initiative (VQI)-Medicare linked database was queried for patients with symptomatic PAA who underwent OPAR or EPAR from January 2010 to December 2018. Kaplan-Meier estimates, log-rank tests and multivariable Cox proportional hazard regression were employed to study the outcomes of amputation free survival (AFS), freedom from first reintervention, freedom from major amputation, and overall survival in 2years following the index procedure. A total of 1,375 patients were studied, of which 23.7% (n=326) were treated with EPAR. Patients treated with OPAR were younger, less likely to have coronary artery disease (CAD) and chronic kidney disease (CKD), but more likely to be smokers and to present with acute lower extremity ischemia. OPAR treated patients had better 2-year AFS (84.5% vs. 72.5%, P<0.001) and overall survival (86.2% vs. 74.7%, P<0.001). Freedom from major amputation at 2years were comparable between EPAR and OPAR (95.5% vs. 97.7%, P=0.164) in the overall cohort. Within the sub cohort of patients with acute limb ischemia, freedom from major amputation was significantly higher for OPAR compared to EPAR (97.4% vs. 90.6%, P=0.021). After adjustment for confounders, OPAR was associated with decreased risk of amputation or death (aHR, 0.62; 95% CI, 0.48-0.80; P<0.001) and mortality (aHR, 0.63; 95% CI, 0.48-0.81; P<0.001) at 2years. OPAR and EPAR had comparable adjusted risk of 2-year major amputation in the overall cohort. However, for patients presenting with acute limb ischemia OPAR was associated with 72% lower risk of 2-year major amputation compared to EPAR (aHR, 0.28; 95% CI, 0.10-0.83; P=0.021). In this multi-institutional observational study of symptomatic popliteal aneurysms, OPAR was associated with significantly better amputation free and overall survival compared to EPAR. For patients with acute limb ischemia, OPAR was associated with reduced risk of amputation. These findings suggest that OPAR may be superior to EPAR in the treatment of symptomatic PAA. A consideration of OPAR as first line definitive treatment for symptomatic PAA patients who are good surgical candidates is suggested.

Admission monocyte to high density lipoprotein cholesterol ratio predicts amputation in patients undergoing embolectomy for acute lower extremity ischemia.

Acute limb ischemia is a common clinical manifestation of embolism or thrombosis, which can lead to amputation. Increasing evidence suggests that various biomarkers can predict amputation at the time of admission. Identifying an easily obtainable and inexpensive indicator has always been a major objective. The aim of this study was to determine the predictive value of the admission monocyte count to the HDL-C ratio for a lower extremity amputation in patients undergoing embolectomy for acute limb ischemia. This retrospective, single-center study included 269 patients who underwent an emergent embolectomy. The study population was divided into two groups according to early amputation: the non-amputation group (n = 220) and the amputation group (n = 49). Two groups were compared based on various data. According to the multivariate regression analysis, patients with a higher CRP and MHR have a significantly higher amputation rate (HR: 1.148; CI: 1.075-1.225; p < 0.001 and HR: 1.547; CI: 1.003-2.387; p = 0.04, respectively). Patients with arterial back bleeding have a significantly lower amputation rate (HR: 0.106; CI: 0.02-0.558; p = 0.008). Our study demonstrated that preoperative CRP, MHR, and no arterial back bleeding after surgery were found to be independent predictors of amputation as a poor prognostic factor within 30 days after an embolectomy.

Dynamika pokaznykiv yakosty zhyttia u khvorykh na infarkt miokarda z krytychnoiu ishemiieiu nyzhnikh kintsivok pid vplyvom kompleksnoho likuvannia z vykorystanniam arhinin-karnitynovoi sumishi ta standartnoho protokolnoho likuvannia

Introduction. The presence of critical lower extremity ischemia (CLEI) in patients with acute coronary syndrome (ACS) limits the possibility of early invasive interventions and determines the tactics of medical preparation for surgery and prevention of complications. The aim of the study. To assess the dynamics of life quality using the EQ-5D-5L questionnaire in patients with myocardial infarction (MI) in combination with obliterative atherosclerosis of the main vessels at the stage of critical lower extremity ischemia and high risk of cardiac complications in the inpatient phase of treatment under the influence of metabolic therapy. Materials and methods. 67 patients with ACS (MI) in combination with CLEI due to stenotic atherosclerosis of the iliac-femoral arterial segment were examined: 35 patients of the main group who underwent emergency balloon angioplasty and infarct-dependent coronary artery stenting in addition with L-arginine/L-carnitine complex (“TIVOR-L”; “Yuri-Pharm”; in the form of intravenous infusions for seven days of 100.0 ml once / day). 32 patients in the comparison group received only standard protocol treatment. All patients, in addition to general clinical, laboratory and instrumental methods, were additionally assessed for quality of life according to the EQ-5D-5L questionnaire. Statistical processing of indicators was performed by the method of variation statistics. Samples were checked for normality of data distribution according to the test of S. Shapiro – M. Wilk, parametric (t-test, Student’s test) methods were used. Confidence interval (CI) and relative risk (RR) were used to more accurately assess the accuracy. Results. In patients of both groups, the severity of the clinical condition did not differ significantly and was due to typical manifestations of ACS and CLEI. In patients of the main group, the use of intravenous infusions of arginine-carnitine mixture against the background of the standard protocol treatment program led to the elimination of anginal syndrome in all patients and reduced functional class of acute heart failure. When evaluating the effectiveness of the proposed combination treatment and its subjective perception by patients, it was found that initially patients of both groups evaluated their quality of life with similar relatively low scores: an average of 26.14 ± 10.15 and 25.68 ± 9.74 points (p-value more than 0.05). We note a significantly higher assessment of quality of life in patients after a course of comprehensive treatment, whose quality of life index improved by an average of 160.9 % and reached the level of 86.5 ± 8.3 points. During the standard treatment program in patients with ACS in combination with CLEI there was a significant improvement in well-being, the total quality of life index increased by 40.2 %. Сonclusions. Patients in the experimental group with acute coronary syndrome and critical lower extremity ischemia who received arginine-carnitine mixture in addition to complex standard protocol drug treatment had significantly reduced feelings of chest pain/discomfort and anxiety / depression and tended to increase motor activity.

Single-Center Experience With JETi Aspiration Thrombectomy for Acute and Subacute Lower Limb Ischemia

Acute lower extremity ischemia (ALEI) is a vascular surgery emergency with significant morbidity and mortality. Percutaneous aspiration thrombectomy is an alternative approach to removing thrombus from peripheral arteries. We evaluated the outcomes of ALEI treated with percutaneous aspiration thrombectomy using the JETi device.

COVID-19–related Peripheral Arterial Thrombosis Treated in a Large Health Maintenance Organization

BackgroundCOVID-19 was initially identified as an acute respiratory disease, but it was quickly recognized that multiple organ systems could be affected. Venous thrombosis and pulmonary embolism have been well reported. However, there is a paucity of data on COVID-19–related arterial thrombosis. We examined the incidence, characteristics, treatment, and outcome in patients with acute COVID-19–related arterial thrombosis in a large health maintenance organization (HMO).MethodsA retrospective multicenter case review was performed from March 2020 to March 2021. Cases were identified through a questionnaire sent to vascular surgeons. Patient characteristics, imaging, treatment, and outcome were reviewed. Successful revascularization was defined as restoration of blood flow with viability of the end organ and absence of death within 30 days. Limb salvage was defined as prevention of major amputation (transtibial or transfemoral) and absence of death in 30 days.ResultsThere were 37,845 patients admitted with COVID-19 complications during this time. Among this group, 26 patients (0.07%) had COVID-19–related arterial thrombosis. The mean age was 61.7 years (range, 33–82 years) with 20 men (77%) and 6 women (23%). Ethnic minorities comprised 25 of 26 cases (96%). Peripheral arterial disease (PAD) was present in 4 of 26 (15%), active smoking in 1 of 26 (3.8%), and diabetes in 19 of 26 (73%) cases. Most patients developed acute arterial ischemia in the outpatient setting, 20 of 26 (77%). Of the outpatients, 6 of 20 (30%) had asymptomatic COVID-19 and 14 of 20 (70%) had only mild upper respiratory symptoms. Distribution of ischemia was as follows: 23 patients had at least one lower extremity ischemia, one patient had cerebral and lower extremity, one had mesenteric and lower extremity, and one had upper extremity ischemia. Revascularization was attempted in 21 patients, of which 12 of 21 (57%) were successful. Limb salvage was successful in 13 of 26 (50%) patients. The overall mortality was 31% (8/26).ConclusionsOur experience in a large HMO revealed that the incidence of COVID-19–related arterial thrombosis was low. The actual incidence is likely to be higher since our method of case collection was incomplete. The majority of arterial thrombosis occurred in the outpatient setting in patients with asymptomatic or mild/moderate COVID-19 respiratory disease. Acute ischemia was the inciting factor for hospitalization in these cases. Acute lower extremity ischemia was the most common presentation, and limb salvage rate was lower than that expected when compared to ischemia related to PAD. Arterial thrombosis associated with COVID-19 portends a significantly higher mortality. Education of primary care providers is paramount to prevent delayed diagnosis as most patients initially developed ischemia in the outpatient setting and did not have a high cardiovascular risk profile.

Reverse \u201ccheese wire\u201d fenestration for abdominal aortic dissection repair: a case report and literature review

BackgroundAortic dissection is one of the most common emergency condition leading to internal organs or lower limb ischemia and aortic rupture. Herein, we described a reverse “cheese wire” endovascular fenestration repair (CWFER) in a patient with complicated abdominal aortic dissection which had never been reported.Case presentationA 62-year-old male presented abdominal tear-like pain and acute ischemia of the right lower extremity during the endovascular treatment of celiac trunk aneurysms. Computed tomography angiography (CTA) and digital subtraction angiography (DSA) showed abdominal aortic type B dissection with acute ischemia of the right lower extremity preoperatively. After a detailed preoperative examination, the patient then was performed a reverse CWFER. So far, the patient has been followed-up for 6 months, postoperative CTA demonstrated good stent-graft expansion and perfusion of bilateral common iliac arteries; also, no endoleak was detected.ConclusionsThe right iliac artery in this patient supplied by false lumen, which lead to acute ischemia of the right lower extremity, needed to be treated as an emergency and dealt with promptly. CWFER is a very high-risk treatment that requires the rich experience of vascular surgeon and accurate assessment of aortic dissection. After interventional treatment, the patient recovered uneventfully after 6 months’ follow-up.