Acute Lower Extremity Ischemia Research Articles

Surgery for Acute Type A Dissection With the Tear in the Descending Aorta Using a Stented Elephant Trunk Procedure

Surgical management of acute type A dissection with the tear in the descending aorta is challenging because of the technical difficulty in managing proximal and distal aortic lesions through a median sternotomy or lateral thoracotomy using a single-stage procedure. Thirty-three patients with acute type A dissection with the tear in the descending aorta underwent total arch replacement combined with stented elephant trunk implantation through a median sternotomy from April 2003 to June 2007. Preoperative complications included acute cardiac tamponade (n = 1), acute left heart failure (n = 1), acute myocardial infarction (n = 1), cerebral ischemia (n = 1), acute renal failure (n = 2), chronic renal dysfunction (n = 2), and acute mesenteric ischemia (n = 1) and lower extremity ischemia (n = 3). The residual false lumen was evaluated using postoperative computed tomography. Death at 30 days was 6.06% (2 of 33 patients). One patient with preoperative mesenteric ischemia died of postoperative multiple-organ failure. One patient with preoperative acute renal failure ceased treatment after three reoperations owing to uncontrollable bleeding. Left lower-extremity paraparesis occurred in 1 patient, and transient neurologic dysfunction occurred in 1 patient. Severe complications were not observed at a mean follow-up of 25 +/- 11 months. Thrombus obliteration of the false lumen was observed at the distal end of the stented graft in 29 patients (96.7%) and at the diaphragmatic level in 20 patients (66.7%) during follow-up. Encouraging outcomes favor this technique in patients with acute type A dissection with the tear in the descending aorta. Simultaneous repair of proximal aortic lesions and thrombosis of the false lumen in the descending aorta could be obtained.

Do Randomized Trials of Thrombolysis Versus Open Revascularization Still Apply to Current Management: What Has Changed?

Several randomized trials of catheter-directed thrombolysis versus operative revascularization in patients with acute lower extremity ischemia were performed in the mid-1990 s. Although the outcomes of these trials were not definitive, they did provide insight into potential uses and techniques of catheter-directed thrombolysis and lytic agents. This article reviews the outcomes of these randomized trials and describes advances in thrombolytic techniques and technology, including percutaneous mechanical thrombectomy devices and innovative catheter designs that accelerate lysis and the development of direct-acting lytic agents.

Effect of Duplex Arteriography in the Management of Acute Limb-Threatening Ischemia From Thrombosed Popliteal Aneurysms.

The role of routine use of duplex arteriography to diagnose thrombosis of popliteal artery aneurysm as a cause of acute lower extremity ischemia is investigated. In all, 109 patients (group 1) from 1994 to 1997 and 201 patients from 1998 to 2001(group 2) presenting with acute limb-threatening ischemia were studied. None of the group 1 patients underwent preoperative duplex arteriography, and no diagnosis of acute popliteal artery aneurysm thrombosis was made. Ten patients with acute ischemia due to thrombosed popliteal artery aneurysm were identified in group 2 when preoperative duplex arteriography was routinely performed. Urgent revascularization was performed based on the results of duplex arteriography. Six patients had functioning bypasses with a mean follow-up of 15.6 months. There were 3 deaths, 2 within 30 days and 1 after 2(1/2) years with functioning grafts. One patient was lost to follow-up. Routine use of duplex arteriography may provide the diagnosis and may identify the available outflow vessels for popliteal artery aneurysm.

Acute Lower Extremity Ischemia Secondary to Salivary Gland Tumor Embolus

Malignant arterial tumor emboli of sufficient size that is capable of causing organ infarction or ischemia are exceedingly rare. The majority of these emboli are associated with either primary or secondary pulmonary malignancies and commonly occur perioperatively or immediately postoperatively. This study describes an unusual case of acute lower extremity ischemia secondary to a malignant parotid tumor embolus with evidence of left ventricular involvement.

Profunda femoris artery aneurysms: Association with aneurysmal disease and limb ischemia

Because there is a paucity of data about management and outcome of true profunda femoris artery aneurysms (PFAAs), we reviewed our 21-year experience with surgical repair of PFAAs. Clinical data from the 15 patients who underwent repair between 1985 and 2006 were retrospectively reviewed. Fifteen men had 17 PFAAs (mean diameter, of 3.4 cm). Three had an acute presentation with rupture (n = 2) or acute limb ischemia (n = 1), one had local tenderness, and 11 were asymptomatic. Sizes of the ruptured PFAAs were 1.5 and 7.5 cm. Eleven patients (73%) had synchronous aneurysms, most frequently in the popliteal artery (n = 7). Three of the asymptomatic patients required an emergency operation because of acute lower extremity ischemia caused by thrombosis of a synchronous popliteal aneurysm (n = 2) or for a ruptured iliac aneurysm (n = 1). Aneurysmectomy with graft interposition between the common femoral and PFA was used in 15 repairs. Ligation alone was used for one aneurysm, and another was treated by partial aneurysmectomy with primary repair. There were no deaths, graft thrombosis, or limb loss at 30 days. At a mean follow-up of 28 months (range, 3 to 108 months), one patient required above knee amputation 2 years after aneurysm ligation, and another patient presented with a recurrent aneurysm. Long-term graft patency was 100%. PFAAs are rare but often occur with synchronous aneurysms. One-third of patients presented with complications of limb ischemia or rupture caused by their PFAA or synchronous aneurysms. Good-risk patients with a PFAA >2 cm should undergo elective repair. Aneurysmectomy with femoral interposition graft is a durable repair.

Development of catheter-directed intrathrombus thrombolysis with plasmin for the treatment of acute lower extremity arterial occlusion

Catheter-directed thrombolysis is an important treatment option for many patients with acute lower extremity ischemia due to arterial and/or graft thrombosis. A growing body of evidence demonstrates that thrombolytic therapy for acute limb ischemia reduces the need for amputation; however, bleeding complications are more likely with lytic therapy. New direct-acting fibrinolytic compounds are being developed that facilitate thrombolysis while reducing the risk of bleeding. Plasmin, the active enzyme produced by all plasminogen activators, works directly upon thrombus and is neutralized instantly in the systemic circulation. This report reviews the principles for effective catheter directed thrombolysis for acute arterial occlusions and describes the development and evaluation of the new thrombolytic, plasmin.

Bilateral Persistent Sciatic Arteries Complicated with Acute Left Lower Limb Ischemia

Persistent sciatic artery (PSA) is a rare congenital malformation. In the early embryonic stage, the sciatic artery is the major blood supply for the lower limb bulb and is later replaced by the iliofemoral artery as the limb develops. Its failure to regress, sometimes associated with femoral arterial hypoplasia, and therefore becoming the dominant inflow to the lower extremity is called PSA. This anomaly is often associated with a higher rate of aneurysm formation or thromboembolic complications causing lower extremity ischemia. Here, we describe a 79-year-old male patient who presented with acute left lower extremity ischemia. He was treated initially with conventional embolectomy through inguinal and popliteal incisions. The bilateral PSA with thrombosed aneurysms was not identified at first on computed tomographic angiography. It was later diagnosed intraoperatively due to the discontinuity of the superficial femoral artery and popliteal artery found with embolectomy catheter, and was managed successfully with ePTFE graft bypass. Careful interpretation of the imaging study may be helpful in preoperative diagnosis.

Contemporary management of acute lower extremity ischemia following percutaneous coronary and cardiac interventional procedures using femoral access—A case series and discussion

New onset of acute lower extremity ischemia following percutaneous coronary and cardiac interventional procedures using femoral access is an important clinical entity that requires emergent assessment to determine the precise etiology and institute appropriate therapy. We report four cases of this clinical event from our catheterization laboratories that serve to highlight the most frequent etiologies, the importance of immediate diagnostic angiography, and the potential for endovascular techniques to effectively manage this complication.

Invited commentary

The study by Gloviczki and colleagues documents their extensive experience with the open surgical repair of popliteal artery aneurysms. Despite the usual limitations of a single-center, retrospective study, it provides an exhaustive amount of information and truly represents the gold standard for comparison with the newer endovascular approaches. The study further confirms the well-known male predominance, prevalence of associated aneurysms, patterns of presentations, and favorable surgical outcomes seen in patients with popliteal artery aneurysms. Several predictors of graft failure were identified, including acute/chronic symptoms, poor arterial runoff, distal anastomotic site, and conduit. Unfortunately, the choice of conduit is usually the only factor among these at the discretion of the surgeon. The authors’ excellent results appear to validate their operative indications, particularly among patients with asymptomatic aneurysms (operative indications, asymptomatic [size >2 cm], presence of mural thrombus, or evidence of thromboembolism). The authors conclude that endoaneurysmorrhaphy is superior to proximal/distal ligation on the basis of an observed significant difference in the freedom-from-reintervention rate (100% vs 98%; P = .03). Although I would contend that the observed difference is likely not clinically significant, their conclusion is likely correct given several recent publications documenting aneurysm growth (and compressive symptoms) after ligation. Unfortunately, the data fail to clarify the role of thrombolysis among patients presenting with acute lower extremity ischemia. However, they do suggest that thrombolysis may confer an advantage in properly selected patients. The current results strongly support the greater saphenous vein as the conduit of choice but provide little guidance for the subset of patients in whom it is inadequate. Finally, it is interesting to reflect on the current results in light of the expanding list of publications documenting the feasibility and safety of the alternative endovascular approach. Interestingly, poor arterial runoff, a predictor of graft failure in this study, was an exclusion criterion in the randomized, controlled trial comparing open and endovascular popliteal artery aneurysm repair cited previously (see reference 23). It is conceivable that the endovascular approach may be equivalent to open repair for asymptomatic patients with good arterial runoff, although this needs to be confirmed by long-term follow-up. Early complications and long-term outcome after open surgical treatment of popliteal artery aneurysms: Is exclusion with saphenous vein bypass still the gold standard?Journal of Vascular SurgeryVol. 45Issue 4PreviewPopliteal artery aneurysms (PAAs) are rare, but thromboembolic complications may result in limb loss. To define complications and outcomes after open surgical repairs, we reviewed our experience. Full-Text PDF Open Archive

Treatment of an Acute Common Iliac Artery Occlusion with Mechanical Thrombectomy and Stenting

We report a case of acute lower extremity ischemia caused by occlusion of the right common iliac artery (CIA), which we treated with mechanical thrombectomy followed by stent placement. The current role of mechanical thrombectomy in the treatment of acute limb ischemia is discussed. Considerations in primary stenting for acute arterial occlusions are presented. We briefly review the role of computed tomographic angiography (CTA) in the evaluation of patients with acute limb ischemia.

Fresh Arterial Grafts as Conduits for Vascular Reconstructions in Transplanted Patients

Objectives To assess the outcome of arterial allografts in patients receiving organ transplantation. Design From October 1997 to June 2005, we used fresh arterial allografts as vascular conduits in 21 patients for the treatment of claudications (10), abdominal aortic aneurysm (6), complicated renal transplantation (2), acute lower extremity ischemia (2) and gangrene (1). At the time of the vascular procedure, ten of the patients (Group A) had already undergone organ transplantation. The mean follow up period was 32 months for renal and 37 months for heart recipients, respectively. In 11 patients (Group B), the vascular reconstruction was undertaken simultaneously with the renal transplantation. The mean follow up period was 49 months. Results There was no arterial allograft related deaths. No signs of arterial graft infection or requirement for secondary intervention (angioplasty and/or thrombolysis) were observed during the follow up period. Conclusions Our experience suggests that it is possible to use fresh arterial allografts in the treatment of arterial occlusive disease or abdominal aortic aneurysm, both in already transplanted patients and simultaneously with organ transplantation, with good results.

Percutaneous ex‐vivo femoral arterial bypass: A novel approach for treatment of acute limb ischemia as a complication of femoral arterial catheterization

This report describes the use of a percutaneous ex-vivo femoral arterial bypass in three patients with acute lower extremity ischemia that occurred as a complication of femoral artery catheterization. Utilizing standard equipment and techniques, a percutaneous ex-vivo femoral artery bypass can restore antegrade flow to the ischemic limb in patients with impaired aorto-iliac inflow circulation, which may arise from iatrogenic dissection or the need for large in-dwelling sheaths required for hemodynamic support. This technique is considered a temporizing measure when conventional therapies are not possible. Contrast angiography is recommended to localize and define the cause of limb ischemia, and to permit safe placement of vascular sheaths in the "donor and recipient" arteries.

Fresh Arterial Grafts as Conduits for Vascular Reconstructions in Transplanted Patients

To assess the outcome of arterial allografts in patients receiving organ transplantation. From October 1997 to June 2005, we used fresh arterial allografts as vascular conduits in 21 patients for the treatment of claudications (10), abdominal aortic aneurysm (6), complicated renal transplantation (2), acute lower extremity ischemia (2) and gangrene (1). At the time of the vascular procedure, ten of the patients (Group A) had already undergone organ transplantation. The mean follow up period was 32 months for renal and 37 months for heart recipients, respectively. In 11 patients (Group B), the vascular reconstruction was undertaken simultaneously with the renal transplantation. The mean follow up period was 49 months. There was no arterial allograft related deaths. No signs of arterial graft infection or requirement for secondary intervention (angioplasty and/or thrombolysis) were observed during the follow up period. Our experience suggests that it is possible to use fresh arterial allografts in the treatment of arterial occlusive disease or abdominal aortic aneurysm, both in already transplanted patients and simultaneously with organ transplantation, with good results.

Comparison of functional parameters of constitutive and hypoxia-induced expression plasmids during acute ischemia of lower extremities

Comparison of functional parameters of constitutive and hypoxia-induced expression plasmids during acute ischemia of lower extremities

Safety and Efficacy of Reteplase for the Treatment of Acute Arterial Occlusion: Complexity of Underlying Lesion Predicts Outcome

We evaluated both the safety and efficacy of reteplase for treatment of acute arterial occlusion as well as outcomes based on treatment of the underlying lesion. From November 2000 to February 2004, reteplase was used to treat arterial occlusions in 81 patients. Catheter-directed intrathrombus thrombolysis was performed with reteplase (0.5 units/hr) continuous infusion. Percutaneous mechanical thrombectomy (Angiojet) was performed in 61% (n = 50) of patients prior to thrombolysis. Unmasking of significant lesions resulted in endovascular intervention (39.5%), open surgical repair (24.6%), or both endovascular and surgical repair (9.8%) of the lesion. No lesion was found in 25.9% of patients. Major and minor complication rates as well as restoration of patency, limb salvage, and amputation-free survival were evaluated. Eighty-one patients received reteplase therapy (median = 10.3 +/- 5.3 units, 19.5 +/- 7.4 hr) followed by next-day arteriogram to assess thrombus removal. Technical success was achieved in 96.2% (n = 78) of cases. Kaplan-Meier life table analysis revealed overall primary patency rates of 76.3%, 60.1%, and 51.6%, at 1, 6, and 12 months, respectively. Overall amputation-free survival rates were 86.4%, 76.4%, and 69.7% at 1, 6, and 12 months, respectively. When subdivided into postlysis intervention, the lysis-only group achieved increased patency (p = 0.0143) and increased limb salvage (p = 0.0219) at 1 year compared to the lysis and endovascular intervention and the lysis and surgical groups. The 30-day complication rate was 17.3% (n = 14), with a major complication rate of 4.9% (n = 4) and a minor complication rate of 12.3% (n = 10). There were no intracranial hemorrhagic complications. Intra-arterial catheter-directed infusion of reteplase for acute lower extremity ischemia is safe and efficacious, as shown by the low risk of bleeding complications, high limb salvage rates, and low mortality rates in this study. The complexity of the lesion that is unmasked through thrombolytic therapy is a predictor of patency and limb salvage.

Embolus of surgical adhesive to the extremities causing acute ischemia: Report of two cases

We present 2 cases in which a surgical adhesive embolized to the extremities. In the first case an adhesive was successfully used in the repair of a DeBakey type I aortic dissection. The patient was seen 2 months postoperatively with acute lower extremity ischemia, and a large piece of adhesive was extracted from the iliac and femoral arteries at embolectomy. In the second case the adhesive was used to seal a pericardial patch during repair of a ventricular septal defect. This patient was seen 1 day postoperatively with acute arm ischemia, and the adhesive particle was extracted from the brachial artery during embolectomy.

Acute lower extremity ischemia in a 7-year-old boy: an unusual case of popliteal entrapment syndrome

Popliteal artery entrapment syndrome is a rare cause of acute limb ischemia that most commonly is seen in young adults. The most significant complications associated with popliteal entrapment include aneurysm formation and acute thrombosis. This case presents the youngest patient ever reported with this syndrome and highlights the advantages of multimodal treatment including thrombolysis, popliteal aneurysm resection, and revascularization. Although a significant body of literature exists on popliteal entrapment syndrome in teenagers and young adults, it has not been reported previously in a patient younger than 11 years. Limb salvage was achieved in this patient with a combination of endovascular and surgical techniques

A national and single institutional experience in the contemporary treatment of acute lower extremity ischemia.

To determine the contemporary clinical relevance of acute lower extremity ischemia and the factors associated with amputation and in-hospital mortality. Acute lower extremity ischemia is considered limb- and life-threatening and usually requires therapy within 24 hours. The equivalency of thrombolytic therapy and surgery for the treatment of subacute limb ischemia up to 14 days duration is accepted fact. However, little information exists with regards to the long-term clinical course and therapeutic outcomes in these patients. Two databases formed the basis for this study. The first was the National Inpatient Sample (NIS) from 1992 to 2000 of all patients (N = 23,268) with a primary discharge diagnosis of acute embolism and thrombosis of the lower extremities. The second was a retrospective University of Michigan experience from 1995 to 2002 of matched ICD-9-CM coded patients (N = 105). Demographic factors, atherosclerotic risk factors, the need for amputation, and in-hospital mortality were assessed by univariate and multivariate logistic regression analysis. In the NIS, the mean patient age was 71 years, and 54% were female. The average length of stay (LOS) was 9.4 days, and inflation-adjusted cost per admission was $25,916. The amputation rate was 12.7%, and mortality was 9%. Decreased amputation rates accompanied: female sex (0.90, 0.81-0.99), age less than 63 years (0.47, 0.41-0.54), angioplasty (0.46, 0.38-0.55), and embolectomy (0.39, 0.35-0.44). Decreased mortality accompanied: angioplasty (0.79, 0.64-0.96), heparin administration (0.50, 0.29-0.86), and age less than 63 years(0.27, 0.23-0.33). The University of Michigan patients' mean age was 62 years, and 57% were men. The LOS was 11 days, with a 14% amputation rate and a mortality of 12%. Prior vascular bypasses existed in 23% of patients, and heparin use was documented in 16%. Embolectomy was associated with decreased amputation rates (0.054, 0.01-0.27) and mortality (0.07, 0.01-0.57). In patients with acute limb ischemia, the more widespread use of heparin anticoagulation and, in select patients, performance of embolectomy rather than pursuing thrombolysis may improve patient outcomes.

Thrombolysis in the Management of Lower Limb Peripheral Arterial Occlusion—A Consensus Document

The aim of this paper is to develop an intercontinental consensus on the use of thrombolytic therapy in occlusive peripheral arterial disease affecting lower limbs. A working party of self-designated angiologists, hematologists, interventional radiologists, and vascular surgeons of Europe and North America convened at 4 closed meetings. All published data known to any of the participants was entered into discussion. The working party discussed the topics outlined in this paper and a first draft was prepared in segments by members of the working party, discussed, and further revised into an interim report. It was then circulated to a number of Societies for their input. A final meeting of the Working Party together with delegates of the Societies collaborated on the definitive version of the text. The Party appreciates that in many areas the scientific evidence is not yet available. Nevertheless, it was felt that enough practical and scientific data were available to establish recommendations for clinical practice as well as for reporting results of thrombolytic therapy, which could be updated as later evidence became available. The guidelines apply only to drugs currently available for clinical use. The data are also considered to be sufficiently cogent that regulatory agencies should move to approve thrombolytic agents for intra-arterial therapy of acute lower extremity ischemia.

The Trellis Thrombectomy System in the treatment of acute limb ischemia.

To report the use of a new percutaneous mechanical thrombectomy device in the treatment of acute limb-threatening ischemia. The Trellis Thrombectomy System is a 7-F drug dispersion catheter that features a treatment segment isolated by proximal and distal occlusion balloons, which help prevent distal embolization and systemic release of the infused thrombolytic agent. After inflating the distal balloon, the thrombolytic agent is infused and held at the target site by inflation of the proximal balloon. An oscillating dispersion wire optimizes dispersal of the thrombolytic agent as the thrombus is mechanically fragmented. The liquefied thrombus is then aspirated. Four consecutive patients with acute lower extremity ischemia secondary to bypass graft thrombosis were treated with the Trellis thrombectomy catheter. Overall, 95% of thrombus was successfully removed from the treatment zone, with no device-related complications. Only one patient required adjunctive thrombolytic therapy after thrombectomy with the Trellis device. The Trellis thrombectomy device is a safe and effective technique to isolate the infused thrombolytic agent in association with mechanical fragmentation for rapid blood flow restoration.