Acute Lower Limb Ischemia Research Articles

P1461 Concomitant potential cardioembolic sources in a patient with an acute ischemia of the limb

Abstract Introduction Transesophageal echocardiography (TEE) is the gold standard exam to look for a cardioembolic source in a patient with an otherwise unexplained suspected systemic ischemic event. Purpose: This clinical case aims to illustrate the importance of a thorough TEE evaluation in the presence of a suspected systemic emboli, and to not neglect thoracic aorta evaluation when a potential intracardiac cause has been detected. Case presentation: We present the case of a 55-year-old man, obese (BMI 30kg/m2), active smoker, with no past medical history or medication, and whose father died from an unspecified cardiovascular cause at 45 years-old. He was admitted to the hospital because of an acute ischemia of the right lower limb, for which he underwent urgent percutaneous femoral embolectomy of the limb, with success. During hospitalization, he was referred for a TEE, which showed valves and cavities with no evidence of potential embolic sources. However, he had a thin and hypermobile atrial septum, with no obvious defect after color flow mapping, but with a patent foramen oval (PFO) that was detected after agitated saline injection associated with a Valsalva maneuver, with the passage of 5-25 microbubbles (grade 2/4 shunt) and an atrial septum aneurysm (ASA), with an excursion of the fossa ovalis towards the left atrium of 10.1mm (Figure 1). The ascending aorta was normal, but the descending aorta depicted 2 hypermobile masses, 1 starting at 35cm from the dental arch (transversal area: 0,52cm2), the longest (7cm) starting at 32cm and ending at the aortic arch (transversal area: 1,76cm2). An angio-CT was immediately performed, which depicted an atheromatous calcified plaque in the terminal portion of the aortic arch, giving rise to the image suggestive of thrombus, and extending for about 6cm to the medium third of the descending thoracic aorta. The remaining portions of the aorta and iliac arteries depicted diffuse atheromatous and partially calcified plaques (Figure 2). The patient was submitted to an urgent thoracic endovascular aortic repair with a 26x10cm prosthesis implantation with occlusion of the left subclavian artery and an adequate final clinical result. Syphilis and auto-immune disease were excluded and a diffuse atheromatous disease of the aorta was assumed as the cause of the thrombus and the embolic event. After 16 days, he was discharged asymptomatic and with no signs of chronic ischemia, treated with oral anticoagulation with rivaroxabano, high-dose statin and strict smoking cessation. Conclusion: Cardioembolic source is a heterogeneous entity. In this patient, 2 potential cardioembolic sources were detected: while the PFO and ASA are minor or unclear risk sources of emboli, TEE also allowed for the detection of a large thrombus arising from an atherosclerotic calcified plaque in the thoracic aorta, which was considered a major risk source, thus implying urgent surgery to obviate the risk of further embolic events. Abstract P1461 Figure. Fig.1.POF and ASA;Fig.2.Aortic Thrombus

P835 Mitral valve abscess complicating infective endocarditis

Abstract Funding Acknowledgements n/a Background Health care associated infective endocarditis (HAIE) accounted for u to 30% of infective endocarditis (IE) cases, it tends to affect patients with a poor clinical condition and represents a considerable in-hospital mortality. Case A 75-years old gentleman with end-stage renal failure secondary to polycystic kidney disease had commenced hemodialysis via a tunneled hemodialysis catheter 3 months ago, presented for pre-operative evaluation before vascular surgery for acute left lower limb ischemia, patient gave history of fever for the past month partially responding to antipyretics along with recent ischemic cerebrovascular stroke with no residual neurological deficits. On examination he had a blood pressure of 110/70 mmHg, a heart rate of 100 bpm, a temperature of 38oC, and a harsh pansystolic murmur over the apex. Laboratory results revealed leukocytosis elevated CRP and blood cultures were positive for staphylococcus aureus. Electrocardiography showed sinus tachycardia. Methods and Results 2D-Trans-Thoracic Echocardiography (TTE) revealed the presence of echogenic rounded mobile mass measured 2x2 cm attached to the atrial surface of the posterior mitral valve leaflet. There was a severe mitral valve regurgitation and the regurgitant jet was directed anteriorly swirling around the mass. The left ventricle dimensions and function were normal. 2D-Trans-esophageal Echocardiography(TEE) was done for better visualization of the mass and it"s attachment. The mass was overlying the atrial surface of the posterior leaflet middle P2 scallop with a small echo-lucent cavity (abscess formation) in the leaflet in addition to another smaller mass at the atrial surface of the anterior leaflet. The aortic, tricuspid and pulmonary valves were normal in structure and function Discussion Echocardiography is a crucial imaging modality in a patient with multiple systemic emboli to rule out cardio-embolic source of embolization. TEE is of added value along with TTE in better definition of masses and detection of IE related complication. While the patient was prepared for the vascular surgery to secure the ischemic limb his sensorium was disturbed and became unconscious immediate brain computed tomography showed severe intracranial hemorrhage and the patient died. Conclusions Patient with chronic kidney disease and on hemo-dialysis are highly vulnerable to health care related infective endocarditis and high clinical suspicion should be given in a situation of prolonged fever and embolic events. Mitral valve abscess is a rare complication of infective endocarditis and if occurs it leads to increase mortality. TEE should be an integral part of management of patients with IE to role out serious complications. Abstract P835 Figure. Mitral valve infective endocarditis

A comparative study of postrevascularization limb salvage rate in early versus delayed presentation of rutherford class IIb acute lower extremity ischemia

Background: Acute limb ischemia (ALI) is the most common vascular emergency with potential morbidity and mortality, which can be prevented by early appropriate treatment. Delayed presentation because of diagnostic delays and referrals continues to be a challenge for vascular surgeons. The purpose of this study is to evaluate the postrevascularization limb salvage rate in patients with delayed presenting ALI Rutherford Class IIb and compare it with early presenting ALI in a tertiary referral center in India. Materials and Methods: Fifty-one patients with Rutherford Class IIb acute lower limb ischemia, who underwent revascularization over a period of 2 years from June 2015 to May 2017 at Jain Institute of Vascular Sciences, Bengaluru, were evaluated in this study. Patients were divided into early presenting (<24 h) (n = 10) and delayed presenting (>24 h–14 days) (n = 41), and both the groups were compared with respect to limb salvage at 1 year. Patients with prior vascular intervention, posttraumatic ALI, and Rutherford Class I, IIa, and III were excluded. Results: Both the groups were comparable with respect to demographics, lesion characteristics, and comorbidities. The mean age in the early and delayed presenting groups was similar. Majority of the patients were male. The most common level of occlusion was femoropopliteal segment. All patients underwent transfemoral/transpopliteal thrombectomy + angioplasty/stenting. Fasciotomy was performed in almost half of the patients based on clinical need. The limb salvage rate was 91.67% in the early presenting group, whereas in the delayed presenting group, it was 72.73%, but the difference was not statistically significant (P = 0.178). None of the patients in the early presenting group had morality, whereas it was 12.20% in the delayed group, which was statistically not significant (P = 0.249). Conclusion: In patients with Rutherford Class IIb ALI in spite of delayed presentation, good limb salvage rate can be achieved if revascularized.

Efficacy of the Indigo Penumbra Suction Thrombectomy System in the Treatment of Acute Lower Limb Ischaemia – A Single Centre Experience

Introduction: The treatment of acute lower limb ischaemia is undergoing a paradigm shift moving from open to endovascular therapy. An audit was carried out with the objective of evaluating the initial outcomes of the treatment of lower limb ischaemia using an endovascular approach with the Indigo Penumbra Suction Thrombectomy System (PSTS) in our unit. Methods: Data of patients treated in our unit for acute and subacute lower limb ischaemia with the Indigo Penumbra system between July 2017 and June 2018 was collected and analyzed retrospectively. Results: Twenty eight consecutive patients with a median age of 63 (range 34-87) underwent treatment with the Penumbra suction thrombectomy system. Sixteen patients were male. Twelve were female. Seventeen patients had a previous vascular intervention. All patients presented with acute or subacute lower limb ischaemia. Acute arterial thrombosis was the diagnosis in twenty four patients and four were embolic with underlying chronic diseases. Ten patients presented within three days from the date of onset of symptoms, 9 between 3 and 7 days, 3 between one and 2 weeks and 7 patients presented after more than 2 weeks after onset of symptoms. Eight patients had impaired sensation, two had impaired motor power and two presented with calf tenderness. All patients underwent CT peripheral angiography. Three patients had thrombosed popliteal arteries, two patients had thrombosed stent and one had thrombosed bypass graft. Fifteen patients were managed with thrombolysis in addition to Penumbra Suction. Seventeen patients were admitted to HDU with median stay 2 days (IQR 1-4 days). Technical success was achieved in 20 patients and thirty-day amputation free survival in 21 patients (75%). Conclusion: Penumbra Suction Thrombectomy decreases the requirement and duration of thrombolysis in patient with acute and subacute lower limb ischemia. The PSTS is a successful alternative for the patients with acute or subacute ischaemia with underlying chronic disease who carry a high risk for operative intervention. Disclosure: Nothing to disclose

Influence of Intraoperative Intra-arterial Thrombolysis on Long-term Clinical Outcomes in Patients With Acute Popliteal Artery Aneurysm Thrombosis

Introduction: Acute lower limb ischemia (ALI) after popliteal artery aneurysm (PAA) thrombosis represents a challenging problem. In the last edition in 2017 from European Society for Cardiology specific recommendations for PAA treatment are lacking [1]. Generally for Rutherford grade II ischemia surgery is recommended. Intraoperative intra-arterial fibrinolytic therapy has been proposed as an adjunct to surgical procedure[ 2].The aim of this research was to investigate outcomes of intraoperative intra-arterial thrombolysis in the treatment of acute PAA thrombosis Rutherford grade IIa and IIb in terms of major adverse limb event (MALE), overall survival and intrahospital complications, especially those associated with bleeding. Methods: A total of 156 patients (Rutherford grade IIa and IIb) with acute PAA thrombosis were admitted between January 1st 2009 and January 1st 2015. We divided PAA patients in two groups, those who underwent (20 patients) and those who didn't undergo additional treatment with intraoperative intra-arterial thrombolysis (136 patients). By using covariables from baseline and angiographic characteristics, a propensity score was calculated for each patient. Each patient who underwent intraoperative thrombolysis was matched to 4 patients from non-thrombolysis group. Thus, comparable patient cohorts (20 in thrombolysis and 80 in non-thrombolysis group) were identified for further analysis. Primary end-point was MALE and secondary all-cause mortality. Results: Patients in thrombolysis group received less frequent fasciotomy (20% vs 56.25%, p=0.02), and had longer hospital stay (10.60 vs 7.04, p< 0.01). Same group had more common wound/hematoma related intervention (25% vs 8%, p=0.13) less common MALE events (0% vs 11.25%, p=0.19), but these differences weren't statistically significant. There were no cases of intrahospital death nor major hemorrhage in both groups. After median follow-up of 49 months, the estimated MALE rate was significantly lower in thrombolysis group (30% vs 65%) (χ 2 =11.50, DF=1, P< 0.01, log rank test). On the other hand, after same follow-up, patients in thrombolysis group had significantly lower mortality rate (20% vs 42.65%) (χ 2 =4.87, DF=1, P=0.03, log rank test). Conclusion: Vascunet and Swedish registry for popliteal artery aneurysm showed 30-day amputation rate of 6.5% and 3.3% respectively [3]. Mainly to address this critical issue arose the strategy of initial thrombolytic treatment for ALI associated with PAA thrombosis. Catheter directed intraaterial thrombolysis prior to surgery can achieve extremity revascularization and reestablish patency of small runoff vessels, providing more favorable conditions for open surgical or endovascular repair to follow in semi- urgent, or elective manner [4]. Systematic review published by Kropman et al. showed that the limb salvage rate was not different with preoperative thrombolysis when compared to the patients who did not undergo thrombolysis [5]. In this research we found that intraoperative intra-arterial thrombolysis in treatment of acute PAA thrombosis showed a significant reduction in terms of MALE events and even improves overall survival. No significant differences have been shown between groups in bleeding complications, except loco-regional. Disclosure: Nothing to disclose

Open Versus Endovascular Revascularization for the Treatment of Acute Lower Limb Ischaemia: A Nationwide Cohort Study

Introduction - During the last two decades the treatment of acute lower limb ischemia (ALI) has developed considerably with the introduction of new endovascular techniques but open surgery remains a treatment option.(1) The optimal choice of initial treatment of patients with ALI remains undefined despite considerable research efforts.(2)

Combined treatment (image-guided thrombectomy and endovascular therapy with open femoral access) for acute lower limb ischemia: Clinical efficacy and outcomes.

ObjectivesTo evaluate the effectiveness and safety of combined treatment (image guided thrombectomy and endovascular therapy with open femoral access) for acute lower limb ischemia.MethodsFrom 2009 to 2017, 52 patients (44 men, eight women, mean 67.2 years) underwent combined treatment for acute thrombotic occlusion of lower extremity arteries. The patients presented with acute limb ischemia and we selectively perform combined treatment in the cases with challenging clinical considerations (e.g. various spectrum of thrombus, underlying atherosclerotic lesions). Combined treatment included cutdown of common femoral artery, thrombectomy using a Fogarty balloon catheter, balloon angioplasty, stenting, and catheter-introduced thrombus fragmentation and aspiration. Patients’ medical records were retrospectively reviewed and follow-up data were collected. The technical and clinical success rates and limb salvage were assessed. The Kaplan-Meier method was used to analyze primary patency rates and overall survival rates. Univariate analyses were performed to determine the factors related to clinical outcomes.ResultsTechnical and clinical success rate was 90.4% and 80.8%, respectively. The mean follow-up duration was 26.5 ± 25.8 months. Primary patency was 91.4%, 86.1%, and 74.6% at six months, 1-, and 2-year, respectively. Limb salvage without amputation was 88.5% (46/52). The overall survival rates at six months, 1-, and 3-year were 82.6%, 80.2, and 56.9%, respectively. The 30-day mortality was 5.8% (3/52). Univariate analysis showed that percutaneous transluminal angioplasty (PTA) type (balloon versus stent) was related to clinical failure.ConclusionsCombined treatment can be effective and safe for ALI patients even under challenging clinical conditions.

Radionuclide Patterns of Ischemia in Acute Occlusive Diseases of Main Arteries of Lower Extremities

RelevanceThe problem of diagnosing and treating patients with acute ischemia of the extremities against the background of thrombosis and atherosclerotic lesions of the main arteries remains very complex task and requires the use of various diagnostic methods, and the leading one is radiation diagnostics.The aim of the study. The development of radionuclide patterns of acute lower limb ischemia and assessment of the treatment efficacy in angiosurgical patients using three-phase scintigraphy. Material and methods The radionuclide method was performed to examine 264 patients with acute thrombosis of the main arteries against the background of atherosclerotic lesions of the lower extremities arteries and clinical signs of acute ischemia of the lower extremities of I-III degree according to the classification of I.I. Zatevakhin.ResultsWe defined quantitative and visual signs of acute ischemia, designed radionuclide semiotics, which allowed to detail the damaged tissue of lower extremities and evaluate the efficacy of the conservative or surgical treatment. The study contains clinical examples of patients with varying degrees of acute limb ischemia.ConclusionThe developed radionuclide patterns of acute ischemia in thrombosis of main arteries of the lower extremities allowed to determine the level of arterial occlusion and the degree of acute ischemia, identify the areas of lack of blood supply and necrosis with no clinical signs at an early stage of formation and optimize the treatment strategy.

CLINICAL EVALUATION OF PROGNOSTIC LABORATORY MARKERS AT ACUTE ISCHEMIA OF THE LOWER EXTREMITIES

Objective - the objective of this research was to study the prognostic ability of simplelaboratory markers (neutrophil / lymphocyte ratio and total creatine phosphokinaselevel) to predict important clinical events in patients with acute lower limb ischemia.Material and methods. A retrospective study of the surgical treatment of 109 patients whowere treated in the Department of Acute Vascular Diseases of IGUS named after V.T. ZaitsevNAMSU from 2016 to 2018 for acute thrombosis or embolism of lower limb arteries with IIstage of acute ischemia. To assess the prognostic ability of the neutrophil / lymphocyteratio (NLR), patients were divided into 2 groups: Group IA - patients with NLR &lt;5; GroupIIA - patients with NLR5. To assess the predictive ability of total creatine phosphokinase(CPK), all patients were divided into 2 groups: IB group - patients with a level of CPK notexceeding the upper limit of normal (ULN) more than 10 times, IIB group - patients with atotal CPK more than 10 times higher than ULN. Collection of laboratory tests wasperformed after hospitalization and before surgical treatment. A comparative assessmentin each group of mortality, frequency of amputations, cardiovascular events and renaldysfunction was performed. The probability of these clinical events in a group of patientswith the presence of the both studied criteria was also evaluated.Results. The overall mortality in patients of both groups was 7.34%, in patients of groupIIA, mortality increased to 17.86%, in patients of group IIB - to 22.22%. In patients of bothgroups, the probability of amputation was 16.51%. In patients of group IIA, the probability of loss of limb was 35.71%, while in group IA it was 9.88%. In the IIB group, theprobability of amputation was even greater - 44.44%. In the IB group, amputations wereperformed in 14% of cases. Also in the IIB group, a high probability of renal dysfunctionwas revealed - 44.44%. In patients with a combination of both criteria, the mortality was40%, the frequency of amputations - 60%, the probability of cardiovascular events - 40%,the probability of renal dysfunction - 60%.Conclusions. NLR and total CPK are simple and effective markers of an adverse postoperative course in patients with acute lower limb ischemia. Revealed a strongrelationship between the level of total CPK with the probability of limb loss and renaldysfunction. Using both criteria improves prognostic accuracy.

LEA 24. Synthetic Marijuana and Acute Lower Limb Thromboembolism and Ischemia—A Case Report

LEA 24. Synthetic Marijuana and Acute Lower Limb Thromboembolism and Ischemia—A Case Report

AAA 17. Predisposing Factors for ProGlide Vascular Closure Failure in Sheath Arteriotomies >16F

The ProGlide vascular closure device (Abbott Vascular, Santa Clara, Calif) is approved for the closure of arterial punctures (typically 5F-21F sheath; maximum outer diameter, 26F). However, a rate of closure failure of about 2% to 8% is reported with the use of this device. This study was conducted to analyze factors predisposing to ProGlide failure when ProGlide devices were used for the closure of large-hole (16F-26 F) arteriotomies and to determine the predictive cutoff values of predisposing factors. In this retrospective study, the ProGlide device was used to achieve vascular access site closure in 458 patients undergoing repair of abdominal aortic aneurysm, thoracic aortic aneurysm, and type B aortic dissection or transcatheter aortic valve implantation. The primary end point was ProGlide failure, defined as follows: inability to achieve common femoral artery (CFA) closure; successful repair, development of acute lower limb ischemia and hemodynamic compromise; or delayed pseudoaneurysm formation during the follow-up period, requiring open repair. Overall, ProGlide failure occurred in 7.6% of cases. Factors that predisposed to ProGlide failure included history of peripheral artery disease (P < .001), presence of CFA calcifications (P < .001), depth of the skin puncture site ≥33 mm (P < .0001), body mass index of ≥28.7 kg/m2 (P < .0001), and use of sheath size ≥19F (P < .0001). Factors such as body mass index, history of peripheral artery disease, presence of CFA calcifications, depth of the skin puncture site, and sheath size are significantly associated with ProGlide failure. Hence, careful patient and device selection and operating procedure are paramount to achieve successful outcomes with ProGlide.

Takayasu Arteritis Presenting with Acute Critical Ischemia of Bilateral Lower Limbs

Takayasu Arteritis Presenting with Acute Critical Ischemia of Bilateral Lower Limbs

Clinical efficacy of catheter-directed thrombolysis combined with endovascular interventions for acute lower limb ischemia

Objective: To explore the risk factors and treatment of acute lower limb ischemia with catheter-directed thrombolysis combined with endovascular interventions. Methods: Totally 191 patients (191 lower limbs) with acute lower limb ischemia in department of vascular surgery of the First Affiliated Hospital of Chongqing Medical University from June 2012 to June 2017 who underwent catheter-directed thrombolysis combined with endovascular interventions were collected. According to imaging findings and clinical characteristics, the patients were divided into acute arterial embolism group (n=36) and acute arterial thrombosis group (n=155). The treatment effect, long-term follow-up and the risk factors closely related to primary patency were analyzed. Results: Among the 191 patients, the immediate success rate of surgery was 100%, the amputation rate within 30 days was 8.4% (16/191), and the mortality rate within 30 days was 2.6% (5/191). The mean follow-up was 31.0 (1.0-60.0) months. The 1-year overall survival rate was 92.1% and the 5-year was 79.5%. The primary patency rate was 74.3% within 1 year and 61.5% within 5 years. Primary vascular patency rate within 1 year and 5 years was mainly affected by occlusion segment (OR=3.5, 2.9, P<0.05), outflow tract (OR=3.2, 2.8, P<0.05) and ischemia degree (OR=3.4, 3.6, P<0.05). Conclusion: Catheter-directed thrombolysis combined with endovascular interventions for acute lower limb ischemia is a safe and effective method. Risk factors for primary patency at 1 and 5 years are occlusion segment, outflow tract and ischemia degree.

Factors in ProGlide® Vascular Closure Failure in Sheath Arteriotomies Greater than 16 French

The ProGlide® vascular closure device (Abbott Vascular, Redwood City, CA, USA) is approved for the closure of arterial punctures (typically 5-21 Fr sheath; maximum outer diameter, 26 Fr). However, a failure rate of about 2-8% is reported. This study was conducted to analyse factors predisposing to failure when the devices were used for the closure of large hole (16-26 Fr) arteriotomies, and to determine the predictive cut off values of predisposing factors. In this retrospective study, the ProGlide® device was used to achieve vascular access site closure in 458 patients undergoing repair of abdominal aortic aneurysm, thoracic aortic aneurysm, type B aortic dissection, or transcatheter aortic valve implantation. The primary endpoint was device failure, defined as inability to achieve common femoral artery (CFA) closure; successful repair, development of acute lower limb ischaemia and haemodynamic compromise; or delayed pseudoaneurysm formation during the follow up period, requiring open repair. Overall, ProGlide® failure occurred in 7.6% of cases. Factors that predisposed to failure included a history of peripheral arterial disease (PAD) (p<.001), the presence of CFA calcification (p<.001), the depth of the skin puncture site≥33mm (p<.001), body mass index (BMI) of ≥28.7kg/m2 (p<.001), and use of sheath size≥19 Fr (p<.001). Factors such as BMI, history of PAD, the presence of CFA calcification, the depth of the skin puncture site, and sheath size are significantly associated with ProGlide® failure. Hence, careful patient and device selection and operating procedure are paramount to achieve successful outcomes.

Prognostic risk factors for recurrent acute lower limb ischemia in patients treated with intra-arterial thrombolysis

ObjectiveThe objective of this study was to assess factors predisposing patients to recurrent acute lower limb ischemia (RALLI). MethodsAcute lower limb ischemia patients treated with catheter-directed thrombolysis (CDT) at Tampere University Hospital and Turku University Hospital between March 2002 and December 2015 were included. The patients' baseline demographics, comorbidities, and other characteristics were assessed retrospectively. Significant factors revealed by univariable analysis were tested in a multivariable model for associations with RALLI. A patency analysis was performed, and the risks of reocclusion were identified. The limb salvage rates after reocclusion were evaluated. ResultsAltogether, 303 consecutive patients with a mean age of 71 years (standard deviation, 11.8 years) were included. Of them, 159 (52.5%) were men. A total of 164 (54.1%) native arterial and 139 (45.9%) bypass graft occlusions were initially treated with CDT. On completion of CDT, 204 additional endovascular or conventional surgical procedures on 203 patients were performed to obtain adequate distal perfusion. During a median follow-up of 40 months (interquartile range, 69 months), 40 (24.4%) cases of RALLI occurred in native arteries and 90 (64.7%) in bypass graft patients (P < .001). In native arteries, the absence of appropriate anticoagulant and antiplatelet medication was independently associated with the development of acute reocclusions (hazard ratio, 6.51) in the Cox multivariable regression analysis. The patency rates were 86.6%, 72.2%, and 68.0% at 1 year, 5 years, and 9 years, respectively. In bypass grafts, worsened tibial runoff (crural index III: hazard ratio, 2.40) was independently associated with RALLI. The respective patency rates were 60.5%, 34.0%, and 29.2% for synthetic conduits and 30.8%, 20.5%, and 13.7% for autologous vein grafts at 1 year, 5 years, and 9 years. Altogether, 38 (29.2%) major amputations were performed on patients with reocclusions. Patients with synthetic conduits demonstrated superior limb salvage rates after reocclusion in comparison to native arteries or vein grafts (P = .025). ConclusionsAppropriate post-thrombolytic antiplatelet or anticoagulant treatment after native arterial events is of great importance, but additional data are needed to improve treatment algorithms. Adequate outflow in bypass graft patients is crucial. Patients with prosthetic bypass grafts have superior limb salvage rates after reocclusion.

Acute Type A Aortic Dissection: Pre-Operative Clinical and Radiological Predictors of Outcome

AbstractBackground: Acute type A aortic dissection is a surgical emergency associated with high morbidity and mortality and is still a surgical challenge. The aim of our work is to evaluate the impact of pre-operative clinical status of different malp-erfusion symptoms (according to Penn classification) and radiological findings on surgical outcome of acute type A dissection patients.Aim of Study: Is to report our experience in surgical management of acute type A dissection patients and to deter-mine the impact of pre-operative ischaemia (by Penn class) on post-operative outcome.Patients and Methods: Between January 2012 and De-cember 2014, 30 patients (23 males, 7 females) with acute type A aortic dissection were operated upon at Kasr Al-Aini Cardiac Surgery Unit, Cairo University. All patients presented with severe chest pain and pulse deficit. Their age ranged from 30 to 70 years. 2 patients had bicuspid aortic valve and 8 patients had Marfan syndrome. 3 patients had acute lower limb ischemia, 6 had renal malperfusion and 4 had massive pericardial effusion. All patients had pre-operative multislice CT aortography with 4 patients showing extensive arch tears and 4 patients had dissected coronary arteries on multislice CT of the coronaries. 13 patients had supracoronary conduit replacement of ascending aorta, 13 had modified Bentall operation, and 4 had valve-sparing (David) operation. All patients had circulatory arrest at moderate hypothermia and cerebral protection for open repair of the dissected aortic arch.Results: The mean cross clamp time was 145±25minutes, and total circulatory arrest time was 25±10 minutes. Patients with pre-operative malperfusion had more prolonged and complicated post-operative stay. There was 5 (17%) post-operative mortality: 1 due to massive bleeding, 2 due to prolonged ventilation following stroke, 1 due to hepato-renal failure and 1 due to myocardial failure.Conclusion: Surgical treatment of acute type A aortic dissection is challenging and requires a well-planned strategy to get optimum outcome.Dissection patients with malperfusion syndromes, circum-ferential arch tears, and dissected coronaries carry higher risk of mortality.

Protective Pathways in Ischaemia–Reperfusion: Take the RISK or Lose the Chance

Protective Pathways in Ischaemia–Reperfusion: Take the RISK or Lose the Chance

Comparative analysis of endovascular methods for treatment of acute lower limb ischemia

Acute lower limb ischemia (ALLI) is defined as a sudden decrease in lower limb arterial perfusion, which lasts less than 14 days and threatens a limb viability. This condition is one of the most common emergencies in vascular surgery, requiring immediate diagnosis and treatment, because untimely revascularization of lower limb leads to high amputation rate and mortality in postoperative period.&#x0D; Currently there exist many methods of lower limb revascularization, however, in fact, they all can be divided into two large groups: open, surgical, and endovascular treatment. The choice between them depends on many factors. Since introduction of Fogarty catheter, balloon thromboembolectomy became a «gold standard» in treatment for ALLI. Nevertheless, at the same time endovascular methods appeared, the first one being catheter-based thrombolysis (CBT). Since its appearance, CBT gradually improved with deeper understanding of indications for its use, improvement of the technique of intervention, appearance of different thrombolytic agents and instruments. Nowadays a number of international guidelines determine CBT as a first line treatment of most patients with ALLI.&#x0D; Endovascular thrombectomy techniques appeared in the 90s of XX century as an attempt tocombine advantages of open surgery (rapid and, in ideal conditions, complete restoration of limb perfusion) and of endovascular intervention (minimal invasiveness). They include manual aspiration, rheolytic (hydrodynamic), rotational, aspiration thrombectomy and pharmacomechanical thrombolysis. According to numerous studies, these techniques demonstrate quite impressive results and, probably, in the near future one of them can become a new «gold standard» in treatment for ALLI.

Results of endovascular interventions in acute lower limb ischemia

The aim — to analyze the results of the use of endovascular revascularization methods for acute lower limb ischemia (ALLI) caused by thromboses or embolisms of the lower limb arteries.Materials and methods. An evaluation of the results of revascularization with the use of endovascular interventions in 108 patients with ALLI was performed. Depending on the treatment method, patients were divided into two groups. The first group included 78 patients who had intra‑arterial catheter‑directed thrombolysis, the second group included 30 patients after percutaneous aspiration or mechanical thrombectomy. If hemodynamically significant residual stenoses of arteries which caused thrombosis remained after thrombolysis or percutaneous thrombectomy, balloon angioplasty or stenting were used.Results and discussion. Technical success was achieved in 73 % of patients who underwent thrombolysis. Endovascular or surgical interventions in addition to thrombolysis were performed in 45 % of patients. The number of perioperative complications was 27 %, of which hemorrhagic — 14 %, including intracranial hemorrhages — 3 %. The number of larger amputations was 21 %, mortality — 8 %. The technical success of aspiration thrombectomy was 83 %, mechanical thrombectomy — 100 %. In most cases additional endovascular interventions were required to eliminate residual stenoses.Conclusions. Endovascular revascularization is an effective method for the treatment of acute lower limb ischemia. Majority of patients after thrombolysis and percutaneous thrombectomy have residual stenotic lesions of arteries which caused thrombosis and require additional endovascular or surgical treatment.

PC098. Reassessing the Role of Fasciotomy After Revascularization of Nontraumatic Acute Lower Limb Ischemia

The use of fasciotomies to prevent complications of compartment syndrome after the treatment of acute limb ischemia is widespread; however, minimal objective data support this practice. We present a single-institution experience in which fasciotomies are not regularly performed after revascularization. Using International Classification of Diseases, Ninth Revision and Tenth Revision codes, we identified all patients presenting to UC Davis Medical Center between January 2003 and July 2018 with acute limb ischemia, excluding those with traumatic injuries. Primary outcomes were amputation and new motor deficit. In addition, we summarized our findings in those patients with and without fasciotomies, excluding those with grade III ischemia. We identified 275 limbs treated for acute limb ischemia. Of these, 22 had grade III ischemia and 253 had Rutherford grade I (52), grade IIa (92), or grade IIb (109) ischemia. Of these, 230 (91%) were successfully revascularized, whereas 23 had nonreconstructible disease (Table). The overall amputation rate was 8% (2.6% of revascularized limbs and 65% of nonreconstructible limbs). A total of 11 fasciotomies were performed in the successfully revascularized limbs. Of the 230 limbs with reconstructible disease, 135 limbs had grade I/IIa ischemia and 95 limbs had grade IIb ischemia; 134 of the 135 Rutherford grade I/IIa ischemic limbs did not undergo fasciotomy after revascularization. In this group, 102 limbs (76%) presented with ischemic symptoms >6 hours. Retained motor function after revascularization was seen in 95% of these limbs. New-onset footdrop occurred in 2 of 102 limbs (2%) with >6 hours of ischemic symptoms and none with <6 hours. In the 95 limbs with grade IIb ischemia (Fig), 65 had >6 hours of symptoms. Of these, 58 did not receive a fasciotomy, and 69% of these limbs had improved motor function, 14% had persistent motor deficit, and 7% were amputated. Of the seven receiving fasciotomy, 43% experienced improved motor function, whereas 14% had persistent footdrop, and there were no amputations. In the 30 limbs with <6 hours of ischemic symptoms, 27 did not have a fasciotomy, and 74% of these had improved motor function, 11% had persistent footdrop, and 4% were amputated. Of the three receiving fasciotomy, 67% had improved motor function, and there were no persistent motor deficits or amputations. Our experience demonstrates an acceptable amputation rate and low rate of new-onset motor dysfunction in salvageable limbs, thereby suggesting that fasciotomies may not always be necessary in patients who present with acute limb ischemia due to isolated arterial occlusion.TableOutcomes by Rutherford gradeRutherford INo fasciotomy (n = 48), No. (%)Fasciotomy (n = 0), No. (%)Prolonged ischemia (>6 hours)37 (77.1)0Preserved motor function46 (95.8)0Motor dysfunction1 (2.1)0Amputation00Death1 (2.1)0Rutherford IIaNo fasciotomy (n = 86), No. (%)Fasciotomy (n = 1), No. (%)Prolonged ischemia (>6 hours)65 (75.6)0Preserved motor function81 (94.2)0Motor dysfunction1 (1.2)0Amputation01Death4 (4.7)1Rutherford IIbNo fasciotomy (n = 85), No. (%)Fasciotomy (n = 10), No. (%)Prolonged ischemia (>6 hours)58 (68.2)7 (70.0)Improved motor function60 (70.6)5 (50.0)Motor dysfunction11 (13.9)1 (10.0)Amputation5 (5.9)0Death9 (10.6)4 (40.0)Excludes limbs with nonreconstructable disease. Open table in a new tab