Acute Lower Extremity Research Articles

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.

Outcomes from the ClotTriever Outcomes Registry show symptom duration may underestimate deep vein thrombus chronicity

ObjectiveThe all-comer ClotTriever Outcomes registry assessed indicators of thrombus chronicity in patients with acute, subacute, and chronic lower extremity deep vein thrombosis (DVT). The effectiveness of the ClotTriever System (Inari Medical, Irvine, CA) by chronicity subgroup was also assessed and reported here in this subanalysis. MethodsAll-comer patients with lower extremity DVT were enrolled, with no limitation based on the patients’ symptom duration. Chronicity was assessed three times and compared: before the procedure based on symptom duration, during the procedure based on available pre-thrombectomy imaging, and visual inspection of the extracted thrombus morphology after thrombectomy. Patients were grouped into acute, subacute, and chronic subgroups according to their post-thrombectomy thrombus chronicity based on thrombus morphology. Analyses on baseline and procedural characteristics along with thrombus removal were performed across subgroups. The effectiveness of thrombus removal was determined by Marder scores adjudicated by an independent core laboratory, with a prespecified primary effectiveness end point of complete or near-complete (≥75%) thrombus removal. ResultsOf the 260 treated limbs from 250 patients, using symptom duration alone, 70.7% were considered acute, 20.9% subacute, and 8.4% chronic. Upon visual inspection, the extracted thrombus chronicity was approximately one-third in each subgroup: 32.7% had acute thrombus, 35.4% subacute thrombus, and 31.9% chronic thrombus. Chronicity assessed using symptom duration alone mismatched the post-thrombectomy chronicity in 55.1% of limbs (P < .0001) with 49.0% being more chronic than suggested by the patients’ duration of symptoms. Chronicity assessed using pre-thrombectomy imaging mismatched the post-thrombectomy chronicity in 17.5% of limbs (P < .0001). No patients received thrombolytics and 99.6% were treated in a single session. Complete or near-complete thrombus removal was achieved in a high percentage of limbs regardless of thrombus chronicity: 90.8%, 81.9%, and 83.8% in limbs with acute, subacute, and chronic thrombus, respectively. ConclusionsThis subanalysis from the all-comer ClotTriever Outcomes registry demonstrates that extracted thrombus in DVT may be more chronic than suggested by the patients’ duration of symptoms. The addition of imaging is helpful to determine the ability of thrombus to respond to therapy. Irrespective of thrombus chronicity, the ClotTriever system can be effective at removing acute, subacute, and chronic thrombus in a single-session procedure without the need for thrombolytics.

Total Hip and Femoral Artery Replacement

A 67 year old man presented with acute right lower extremity ischaemia (Rutherford stage IIb) following total hip replacement. Digital subtraction angiography demonstrated occlusion of the femoral bifurcation (red arrow; A). During open surgery, an extensive thermal injury related to the prosthesis implantation was seen on the arterial wall and in the surrounding soft tissue; furthermore, a fistula (white arrow) was detected to the hip joint. The arterial bifurcation was replaced using autologous saphenous vein (B). The patient had an uncomplicated post-operative recovery and was discharged for rehabilitation with a patent vascular reconstruction.

Analysis of incidence/mortality/cost for thrombotic events in hospitalized patients with lung cancer using the National Inpatient Sample database.

12073 Background: Thrombotic events are a common complication of lung cancer. We performed a retrospective analysis of an inpatient adult population (age ≥18) using the National Inpatient Sample (NIS) database from the years 2003-2014. Methods: The analysis was performed on the NIS database, using IBM SPSS Statistics 28.0.0.0 software. The cases for lung cancer were selected based on ICD-9(International Classification of Disease) codes for lung cancer. The cases were weighted by Weight to discharges in the universe. These cases were checked for a diagnosis of acute lower extremity Deep Vein thrombosis (DVT) and acute Pulmonary Embolism (PE) again using ICD-9 codes. Chi square tests were utilized to check the significance of association between mortality and DVT/PE. Independent T-tests were utilized to check the association of cost of hospitalization and length of stay with DVT/PE. Results: There were a total of 4,940,262 cases (53.0% male) of lung cancer from the years 2003-2014. 112,569 (2.3%) cases had a diagnosis of acute lower extremity DVT, and 164,208 (3.3%) cases had a diagnosis of acute PE. Overall, death for lung cancer cases was 516,070(10.5%). Death rate in patients with DVT was 12.4%(frequency = 13,943). DVT and death during hospitalization were positively associated, X 2 (1, N = 4,936,702) = 578.792, p &lt;.001. Rate of death for PE was 15.5% (25,360). PE and death during hospitalization were positively associated as well, X 2 (1, N = 4,936,702) = 4540.012, p.000. DVT was associated with a prolonged length of stay ( M = 8.66 days, SD = 8.8.624), compared to cases without DVT ( M = 6.42 days, SD = 6.42), t(4,940,122) = 115.02, p =.000. DVT was also associated with increased total charges of hospitalization ( M = $ 62,950, SD = 85,105), compared to cases without DVT ( M = $ 41,764, SD = 55,410), t(4,864,517) = 124.09, p =.000. PE was associated with a prolonged length of stay ( M = 8.01 days, SD = 8.13), compared to cases without PE ( M = 6.42 days, SD = 6.41), t(4,940,122) = 97.89, p =.000. PE was also associated with increased total charges of hospitalization ( M = $ 56,161, SD = 76,585), compared to cases without PE ( M = $ 41,772, SD = 55,468), t(4,864,517) = 100.85, p =.000. Conclusions: DVT and PE are common complications of Lung Cancer. They are associated with increased mortality in these patients. DVT increases the mean LOS by 2.24 days, and mean charges by $21,186. PE increases the mean LOS by 1.59 days, and the mean charges by $14,389. Prevention of DVT and PE could help bring down the mortality, LOS and charges of hospitalization. This data provides support to the usage of prophylactic anticoagulation in patients with lung cancer as shown in recent trails with Direct Acting Oral Anticoagulants(DOACs), and further study of DVT/PE in Lung cancer patients would be warranted.

Concomitant acute lower extremity arterial and deep vein thrombosis developing in a patient under anticoagulant therapy after COVID 19 infection.

The hypercoagulable state continues after the Coronavirus 2019 (Covid 19) infection and prophylactic anticoagulants are recommended in this period. However, arterial and venous thromboembolic events can be observed during the convalescence period after the Covid 19. Here, we present the case of acute lower extremity arterial and venous thromboembolism developed in the post-Covid 19 period in a 77-years-old patient, under therapeutic doses of anticoagulant therapy (enoxparin 1mg/kg of weight every 12 hours). The patient, who had no previous history of arterial or venous thrombosis, was taken to emergency surgery with the diagnosis of ALI (acute limb ischemia) due to acute arterial thrombosis. An arterial thrombectomy was performed with the help of a 4F Fogarty catheter inserted from the left femoral artery under local anesthesia. All distal pulses of the patient were palpable in the postoperative period. After the platelet count became &gt;100,000 mm3, 100 mg of acetylsalicylic acid daily was added to the therapeutic dose of enoxaparin sodium treatment. The patient was discharged, uneventfully, except for a minimal diameter increase secondary to deep venous thrombosis (DVT) on the fifth postoperative day, with a combination of enoxaparin and acetylsalicylic acid treatment. Endothelial injury, chronic immuno-thrombogenicity, and increased platelet aggregation in the post-Covid 19 recovery period can cause major thrombotic events, even weeks after the recovery. Anticoagulant therapy is recommended for thromboprophylaxis when the following statuses exist: ≥65 years, critical illness, cancer, prior VTE, thrombophilia, severe immobility, and elevated Ddimer. Combination treatment with long-term antiaggregant therapy may be prudent in thromboembolic events developed under anticoagulant therapy.

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.

Clinical Study on Treatment of Acute Lower Extremity Arterial Embolism With Straub Thrombus Removal System.

BackgroundAcute lower extremity arterial embolism (ALEAE) is a common and frequently occurring disease in clinics. Although thrombectomy with arteriotomy has been widely used and developed in clinics, there is a high probability of embolic recurrence after operation. The present study investigated the clinical efficacy of the Straub Rotarex system in the treatment of ALEAE, as it could remove exfoliative substances in acute and chronic cavities and expose diseased vessels.Materials and MethodsWe accessed our institutional database and retrospectively screened all patients with ALEAEs who received surgical treatment between April 2018 and April 2021. To observe the clinical efficacy, surgical indicators, incidence of postoperative complications, and recurrence rate of treatment with Straub Rotarex system and arteriotomy thrombectomy and analyze the risk factors for recurrence of embolism after treatment with Straub Rotarex system by multivariate Logistic regression model.ResultsFinally, 64 patients were included as the research object. The total effective rates of the observation group and the control group after operation were 100 and 93.75% respectively, and there was no significant difference between the two groups (P > 0.05). The intraoperative blood loss, postoperative off-bed time and hospital stay time in the observation group were significantly lower than those in the control group, and the operation time and hospitalization expenses were significantly higher than those in the control group (P < 0.05). The incidence of postoperative complications in the observation group was 3.13%, which was significantly lower than 18.76% of that in the control group (P < 0.05). The recurrence rates of the observation group and the control group were 15.63 and 18.76%, respectively. There was no significant difference in the recurrence rate between the two groups (P > 0.05). Atrial fibrillation was an independent risk factor for recurrence after the Straub thrombus removal system (P < 0.05).ConclusionStraub thrombus removal system is an effective method for the treatment of ALEAE. Although it prolongs the operation time and increases the operation cost as compared with thrombectomy, it effectively improves the operation safety, postoperative life quality, and postoperative recovery, thus, worthy of clinical promotion. Atrial fibrillation is an independent risk factor for recurrent embolism after the Straub thrombus removal system. Paying attention to the clinical diagnosis and treatment of patients with atrial fibrillation is of great significance for patients to choose a reasonable treatment, prevent a recurrence, and improve the prognosis.

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.

Acute Lower Extremity Posterior Compartment Syndrome: A Rare Complication of Apixaban Use

Apixaban is an oral anticoagulant that directly inhibits Factor Xa and is indicated for the prophylaxis and treatment of deep venous thrombosis and stroke prevention in non-valvular atrial fibrillation. Acute lower extremity Posterior Compartment Syndrome is a rare complication of Apixaban use. We present a 78-year-old male with significant medical morbidities taking Apixaban for Atrial Fibrillation presenting with post-traumatic extensive hemorrhagic bullae on the left proximal pretibial region secondary to anticoagulation.

False lumen thrombus following aortic dissection diagnosed as the source of repeat lower extremity emboli with angioscopy: a case report

BackgroundAcute arterial embolization caused by a free-floating thrombus of the false lumen after surgery for acute aortic dissection is a rare complication; hence, determining its cause may be difficult. We report a case in which angioscopy was valuable in diagnosing and treating the unstable thrombus within the false lumen.Case presentationThe patient was a 71-year-old woman who underwent hemiarch replacement for Stanford type A acute aortic dissection. Two months after the operation, left renal infarction occurred. Eighteen months after the operation, the patient visited the hospital for treatment of intermittent claudication of her left leg. Computed tomography (CT) showed occlusion below the left common femoral artery. Surgical thrombectomy was performed for acute lower extremity arterial occlusion. One month later, thrombectomy was performed again for the same phenomenon and again after 2 months. She had no history of cardiac arrhythmia. No obvious source for the repeat embolization could be found on echocardiography or enhanced CT. Angiography was performed to further identify the cause, revealing a new entry site at the distal anastomosis, which exhibited antegrade flow into the false lumen. Furthermore, selective false lumen angiography via the re-entry revealed a thrombus in the false lumen corresponding to the descending aorta. A non-obstructive angioscopy system in the false lumen revealed a free-floating thrombus. As the patient had undergone multiple surgeries over a short period and desired minimally invasive treatment, coil embolization of the new entry site as well as false lumen was performed. As a result, blood flow from the true to the false lumen resolved. More than 1 year has passed following coil embolization with no signs of embolism.ConclusionsWe experienced a case of repeat embolism caused by unstable thrombus formation in the false lumen resulting from antegrade blood flow in the false lumen secondary to development of a new entry site. Angioscopy revealed that this antegrade flow caused formation of an unstable thrombus which caused recurrent acute lower extremity arterial occlusion. Therefore, angioscopy may be a useful option for the diagnosis of false lumen thrombosis.

Defining the role of risk stratification and duplex ultrasound in the diagnosis of acute lower extremity deep vein thrombosis

ObjectiveRisk stratification using the plasma D-dimer level and Wells score has been proposed as a safe strategy to rule out acute lower extremity deep vein thrombosis (DVT) and limit the use of duplex ultrasound (DUS) for low-risk patients. A widely used diagnostic protocol defining the role of pretest probability and D-dimer testing in lieu of DUS has not been reported. Our aim was to define the risk of DVT in a standard population of emergency department patients who had presented with acute lower extremity symptoms and determine the role of DUS for these patients. MethodsOutpatients presenting to the emergency department with symptoms concerning for lower extremity DVT were prospectively enrolled. All the patients underwent whole leg DUS and clinical and laboratory assessments for DVT using the Wells criteria and plasma D-dimer testing. The patients were stratified into three groups according to the combination of their Wells score and plasma D-dimer level. The prevalence of DVT and the statistical performance of the combined Wells score and plasma D-dimer were compared. ResultsA total of 3087 patients were enrolled. Most of the patients had had a negative plasma D-dimer level and Wells score (n = 2290 patients). A total of 222 patients had had a positive plasma D-dimer level and Wells score. The overall prevalence of acute DVT in the present study was 7.3%. Of the 2290 patients with a negative Wells score and negative plasma D-dimer level, 4 had had a diagnosis of DVT (negative predictive value, 99.8%). In contrast, DVT was present in 181 of 222 patients (81.5%) with a positive Wells score and plasma D-dimer level (positive predictive value, 81.5%). The plasma D-dimer level also correlated with the DVT location, and the D-dimer levels were highest for the patients with proximal DVT. ConclusionsThe combination of a negative Wells score and negative plasma D-dimer level can safely exclude the presence of DVT. Patients with a negative Wells score and negative plasma D-dimer level are unlikely to benefit from DUS. In contrast, patients with a positive D-dimer level and positive Wells score will benefit from whole leg DUS to rule out the presence of high-risk DVT.

Percutaneous Mechanical Atherothrombectomy Using the Rotarex Device in Acute Ischemic Disease of Lower Limbs: A China Retrospective Multicenter Study on 186 Patients

To evaluate the efficacy and safety of the Rotarex mechanical thrombectomy device in treating acute lower extremity arterial ischemia and to explore the appropriate indication of the Rotarex device. A retrospective analysis was performed in 186 patients with acute lower extremity arterial ischemia treated with the Rotarex mechanical thrombectomy device from April 2015 to March 2020 in three vascular surgery centers of Tianjin. As per the comprehensive judgment of the etiology, onset time, imaging of ultrasonography (US) and angiography, and findings during treatment, the patients were divided into the embolization group (69 cases), thrombosis group (primary artery stenosis with thrombosis; 86 cases), and restenosis group (stent restenosis with thrombosis; 31 cases). The primary study outcomes included the success rate of Rotarex mechanical thrombectomy device alone, percutaneous transluminal angioplasty (PTA), stent, catheter-directed thrombolysis (CDT) auxiliary rate, target vessel patency rate, and freedom from clinically driven target lesion revascularization rate (f-CD-TLR). The secondary study outcomes included intraoperative distal arterial embolization, postoperative 30-day bleeding, and deterioration of renal function, amputation, and mortality. The success rate of Rotarex mechanical thrombectomy device alone in the embolization group (44.93%) was significantly higher than that in the thrombosis group (13.95%) and restenosis group (0%) (P<0.01). The PTA auxiliary rate in the embolization group (26.09%) was significantly lower than that in the thrombosis group (72.09%) and restenosis group (100%) (P<0.01). The stent implantation rates in the embolization group and restenosis group(11.60% and 33.30%, respectively) were significantly lower than that in the thrombosis group (72.09%) (P<0.01). There were no significant differences in the CDT auxiliary rate, distal arterial embolization, hemorrhage, renal function deterioration, amputation rate, and mortality among the three groups (P>0.05). The primary patency at 3months, 6months, and 12months postoperatively was 98.6%, 98.6%, and 84.3% in the embolization group, 96.4%, 89.5%, and 74.9% in the thrombosis group, and 93.2%, 84.7%, and 67.5% in the restenosis group, respectively (P<0.01). The f-CD-TLR at 12months postoperatively was 88.9% in the embolization group, which was higher than 77.8% in the thrombosis group and 67.5% in the restenosis group (P<0.01). The Rotarex mechanical thrombectomy device is a minimally invasive, safe, and effective treatment option for acute lower extremity arterial ischemia, particularly acute arterial embolization. For acute thrombosis secondary to primary artery stenosis and in-stent restenosis, Rotarex device can effectively reduce the thrombus burden and create favorable conditions for other concurrent interventions.

Dual energy CT angiography for lower extremity trauma: comparison with conventional CT.

To determine if rapid switching dual-energy CT (rsDECT) provides improvements in vascular attenuation, subjective diagnostic quality, and detection of vascular injuries compared to conventional CT in trauma patients undergoing lower extremity CT angiography. The IRB approved this HIPAA-compliant retrospective study. Informed consent was waived. Thirty-nine patients with acute lower extremity trauma including gunshot wounds (19 patients), falls (6 patients), motor vehicle accidents (5 patients), stab wounds (4 patients), pedestrian struck (2 patients), and unspecified trauma (3 patients) who underwent IV contrast-enhanced rsDECT angiography of the lower extremities on a rapid-kilovoltage-switching dual-energy CT scanner (Revolution CT, GE Healthcare) from 6/4/2019 to 1/14/2021 were studied. 7 patients were initially positive for vascular injury on conventional CT, while 32 patients were negative. Blended CT reconstructions simulating conventional 120 kVp single-energy CT, and rsDECT reconstructions (50keV monoenergetic and iodine density maps) were reviewed. Region of interest contrast density measurements were recorded on conventional and 50keV reconstructions at multiple levels from the distal aorta to the ankles and compared using Wilcoxon signed-rank tests. Vascular contrast density of 150 HU was used as a minimum cutoff for diagnostically adequate opacification. Images were interpreted by consensus for subjective image quality and presence of injury on both conventional and DECT reconstructions by two fellowship-trained abdominal radiologists blinded to clinical data, and compared using the paired McNemar test. Density measurement differences between conventional and rsDECT at every level of the bilateral lower extremities were statistically significant, with the average difference ranging from 304 Hounsfield units (HU) in the distal aorta to 121 HU at the ankles (p < 0.0001). Using a cutoff of 150 HU, 9.5% (93/976) and 3.1% of vascular segments (30/976) were considered non-diagnostic in the conventional and rsDECT groups, respectively, a reduction of 67.7% (p < 0.0001). Subjective image quality between conventional and rsDECT was not statistically significant, but there were 7 vascular segments out of a total of 976 segments across 3 different patients out of a total of 39 patients in which diagnostic quality was upgraded from non-diagnostic on conventional CT to diagnostic on rsDECT, all of which showed suboptimal bolus quality on conventional CT (unmeasurable in 4/7 and ranging from 56-146 HU in the remaining 3). Similarly, rate of injury detection was identical between conventional CT (15/39 patients) and DECT (15/39 patients). Vascular contrast density is statistically significantly higher with rsDECT compared to conventional CT, and subjective image quality was upgraded from non-diagnostic on conventional CT to diagnostic on rsDECT in 7 vascular segments across 3 patients. rsDECT provides greater vascular contrast density than conventional CT, with potential to salvage suboptimal examinations caused by poor contrast opacification.

Interim outcomes of mechanical thrombectomy for deep vein thrombosis from the All-Comer CLOUT Registry

ObjectivesThe multicenter, prospective, single arm CLOUT registry assesses the safety and effectiveness of the ClotTriever System (Inari Medical, Irvine, CA) for the treatment of acute and nonacute lower extremity deep vein thrombosis (DVT) in all-comer patients. Reported here are the outcomes of the first 250 patients. MethodsAll-comer patients with lower extremity DVT were enrolled, including those with bilateral DVT, those with previously failed DVT treatment, and regardless of symptom duration. The primary effectiveness end point is complete or near-complete (≥75%) thrombus removal determined by independent core laboratory-adjudicated Marder scores. Safety outcomes include serious adverse events through 30 days and clinical outcomes include post-thrombotic syndrome severity, symptoms, pain, and quality of life through 6 months. ResultsThe median age was 62 years and 40% of patients had contraindications to thrombolytics. A range of thrombus chronicity (33% acute, 35% subacute, 32% chronic) was observed. No patients received thrombolytics and 99.6% were treated in a single session. The median thrombectomy time was 28 minutes. The primary effectiveness end point was achieved in 86% of limbs. Through 30 days, one device-related serious adverse event occurred. At 6 months, 24% of patients had post-thrombotic syndrome. Significant and sustained improvements were observed in all clinical outcomes, including the Revised Venous Clinical Severity Score, the numeric pain rating scale, and the EuroQol Group 5-Dimension Self-Report Questionnaire. ConclusionsThe 6-month outcomes from the all-comer CLOUT registry with a range of thrombus chronicities demonstrate favorable effectiveness, safety, and sustained clinical improvements.

No false elevation in ankle brachial index in patients with tibial plateau fractures and vascular risk factors

ObjectivesThe ankle brachial index (ABI) is a useful tool in detection of lower extremity vascular injury. However, diabetes mellitus (DM), chronic kidney disease (CKD), and peripheral vascular disease (PVD) may affect extremity perfusion leading to possible false elevation of the ABI value. If true in trauma patients, this can affect initial evaluation, diagnostics, and management. We therefore explored mean ABI values in tibial plateau fractures of patients with vascular risk factors to help determine whether there is a difference. DesignThis is a retrospective chart review of patients sustaining tibial plateau fractures with a specific ABI value recorded in the medical record. Patients were identified as either having vascular risk factors or not and data analysis performed to determine if their ABI differed and whether they were more likely to have a vascular injury. Results282 acute tibial plateau injuries with specific ABI values were identified, 46 of which carried the risk factors in question. The average risk factor group ABI was 0.95 ± 0.15 versus those without risk factors 1.0 ± 0.15 (p = 0.057). No patient with risk factors required a vascular intervention or four-compartment fasciotomy. ConclusionsThis study shows no statistical significance between the presenting ABI of patients with risk factors such as DM, CKD, or PVD and those without those risk factors who sustained acute tibial plateau fractures. Therefore, in general the ABI still holds as a useful screening tool for evaluation of vascular insult in the setting of acute lower extremity trauma.

Outcomes and role of peripheral revascularization in type A aortic dissection (TAAD) presenting with acute lower extremity ischemia

Objective: Limited data exists on management and outcomes of patients presenting with type A aortic dissection (TAAD) and acute lower extremity ischemia (ALI). The role of limb-related revascularization and optimal treatment strategy remains undefined. The objective of this study was to analyze dissection characteristics, treatment modalities, and outcomes of patients undergoing proximal aortic repair for TAAD with ALI.

Acute Lower Extremity Fracture Management in Chronic Spinal Cord Injury: 2022 Delphi Consensus Recommendations.

Information from a previous systematic review that addressed lower extremity fracture care in persons with an SCI as well as information from interviews of physical and occupational therapists, searches of the literature, and expert opinion were used to develop this CPG. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to determine the quality of evidence and the strength of the recommendations. An overall GRADE quality rating was applied to the evidence. Individuals with a chronic SCI who sustain an acute lower extremity fracture should be provided with education regarding the risks and benefits of operative and nonoperative management, and shared decision-making for acute fracture management should be used. Nonoperative management historically has been the default preference; however, with the advent of greater patient independence, improved surgical techniques, and advanced therapeutics and rehabilitation, increased use of surgical management should be considered. Physical therapists, kinesiotherapists, and/or occupational therapists should assess equipment needs, skills training, and caregiver assistance due to changes in mobility resulting from a lower extremity fracture. Therapists should be involved in fracture management as soon as possible following fracture identification. Pressure injuries, compartment syndrome, heterotopic ossification, nonunion, malunion, thromboembolism, pain, and autonomic dysreflexia are fracture-related complications that clinicians caring for patients who have an SCI and a lower extremity fracture may encounter. Strategies for their treatment are discussed. The underlying goal is to return the patient as closely as possible to their pre-fracture functional level with operative or nonoperative management.

Evidence-Based Nursing Model in Interventional Thrombolysis for Acute Lower Extremity Arterial Embolism.

Acute lower extremity arterial embolism (AE) is a serious clinical emergency, and, if not treated in time, it can easily lead to limb ischemia and necrosis and eventually facing amputation, which seriously damages patients' physical and mental health. In the past, the conventional drug thrombolytic therapy had slow and limited efficacy, and the best time for treatment is easily delayed, while arterial dissection and thrombectomy treatment, although fast, is traumatic and has many complications, which is not easily accepted by patients. The aim of this study was to investigate the value of evidence-based care model in the application of interventional thrombolysis for acute lower limb arterial embolism. Seventy-two patients with acute lower limb arterial embolism who underwent interventional thrombolysis treatment received by the Department of Vascular Surgery of our hospital from July 2016 to December 2021 were randomly divided into a control group (given conventional nursing services) and a quality group (given full quality nursing services) to compare the effect of nursing services in the two groups. The results showed that the postoperative psychological status of patients in the quality group was significantly better than that of patients in the control group (P < 0.05). The total incidence of postoperative adverse events and the total treatment efficiency of the quality group were better than those of the control group (P < 0.05). The efficacy of quality nursing care in patients with acute lower extremity arterial embolism is more desirable than conventional nursing care and is recommended. The site of vascular occlusion after bypass surgery can be clarified when angiography is performed after thrombolytic therapy, which can help secondary surgical intervention to prolong the time to patency. The efficacy of quality nursing care in patients with acute lower extremity arterial embolism is more desirable than that of conventional nursing care and is recommended.

Perioperative point-of-care ultrasound for diagnosis of acute lower extremity arterial thrombosis after total hip arthroplasty revision: a case report

PurposeAcute arterial thrombosis after hip arthroplasty is a rare event associated with potentially catastrophic complications. Early clinical diagnosis of progressive limb ischemia is often difficult in the immediate postoperative period because of residual neuraxial blockade and the nonspecific nature of signs. We describe the use of point-of-care ultrasound (POCUS) in the postanesthesia care unit (PACU) to diagnose this complication early and facilitate timely intervention.Clinical featuresA 78-yr-old female patient underwent elective right hip revision arthroplasty under spinal anesthesia and postoperatively had an absent dorsalis pedis pulse on her operative leg as screened by an audible-only Doppler. No obvious clinical symptoms were present as the patient was still under subarachnoidal blockade. A bedside POCUS vascular evaluation was performed in the PACU and showed an absence of blood flow in the superficial femoral artery, expediting the confirmation of a surgical emergency. The patient underwent a successful open thrombectomy and made an uneventful postoperative recovery.ConclusionOur case report highlights the novel use and impact of bedside POCUS to assess the presence or absence of distal limb arterial blood flow and, in this case, the level of arterial occlusion.

The Toddler's Fracture.

The tibial toddler's fracture is an important diagnosis in both emergency and urgent care, presenting as acute onset lower extremity pain or limping in a young child. Diagnosis and management may be challenging because of an extensive differential diagnosis. The objectives of this study were to provide an overview of the toddler's fracture and to guide clinicians by summarizing up to date literature for both diagnosis and management this common condition. This study analyzed literature from the PubMed database from the years of 1964 to 2018. The main focus was on the diagnosis and management of the toddler's fracture. This review demonstrates that diagnosis is primarily made through history and physical examination, as radiographs are often negative at initial presentation. Treatment involves a short period of immobilization, which can be facilitated through the use of a cast, a splint, or no external support. Successful healing and a full return to normal activities and development are near universal. Although a stable fracture with an excellent prognosis, opportunities exist to improve toddler's fractures diagnosis and treatment protocols, to optimize clinical management.