Acute Lower Limb Ischemia Research Articles

Acute limb ischemia due to Candida tropicalis mitral valve endocarditis

Fungal endocarditis is a very rare entity and is associated with high morbidity and mortality rates. We report a 68-year-old man with fungal valvular endocarditis over the mitral valve with a large vegetation located over the anterior leaflet, presenting initially as acute limb ischemia of the left lower limb. Immediate embolectomy was performed for revascularization of the left lower limb. Pathologic section of the retrieved femoral embolectomy specimen revealed aggregated fungal spores and hyphae. Blood cultures were positive for Candida tropicalis. We should be alert to treat patients with acute arterial occlusion of the extremities and to investigate the underlying possible fatal etiology.

Tertiary Center Experience of Catheter-Directed Thrombolysis for Immediately Threatened Acute Lower Limb Ischemia of Native Vessels and Bypass Graft Thrombosis

Background: Catheter-directed thrombolysis (CDT) is an effective therapy and a class I indication for patients with acute limb ischemia (ALI, Rutherford categories I and IIa) of less than 14 days duration, and class IIb indication for ALI (Rutherford category IIb) with symptoms more than 14 days duration. However, there is no consensus on the initial management option for ALI (Rutherford category IIb) with symptoms less than 14 days duration.

Eversion endarterectomy of the external iliac artery

Introduction. To redraw attention to the meaning and value of eversion endarterectomy (EA) of external iliac arteries as a still effective surgical method used in the treatment of advanced arterial occlusive disease. The authors of this article would like to present their experience in this scope. Material and methods. This is a presentation of the applied method of treatment; it comprises the descriptions of nine consecutive cases of patients suffering from atherosclerotic stenosis or occlusion of external iliac arteries and advanced lower limb ischaemia, manifesting in a short distance of claudication, rest pain and commencing necrotic lesions in the lower limbs, who were operated on in the years 2013–2014, for whom the restoration of patency in the external iliac arteries was achieved by use of eversion endarterectomy. It also comprises two other patients for whom the restoration of patency in the external iliac arteries was achieved by eversion endarterectomy but who were operated on for acute lower limb ischaemia. Results. In all but one patient the restoration of patency by eversion endarterectomy was successful, resulted in improvement of blood flow in the limb and reduction of the patients’ ailments. In one case there was no improvement and the patient required more surgical interventions. In the same case a retroperitoneal aneurysm arose, requiring surgical removal. In another case early thrombosis of the operated artery developed and was successfully treated with thrombectomy. The other patients reported alleviation or absence of pain directly after the surgery. In our patients’ group we noted one serious undesired extra-vascular event — a myocardial infarction type 2. Mortality after 30 days was zero. Conclusions. Eversion endarterectomy of the external iliac artery is an effective and relatively simple surgical method of known and proven effectiveness. It constitutes a bit forgotten but valuable supplement to an armamentarium of surgical methods in the treatment of atherosclerosis of an aortoiliac segment.

GW26-e2507 The Effect of Catheter-directed Thrombolysis with Low-dose Urokinase on Acute Lower Extremity limb Ischemia

To evaluate the safety and effectiveness of catheter-directed thrombolysis therapy with low-dose urokinase for acute lower extremity ischemia limb. Retrospective analysis of clinical data of 50 cases, including 27 males and 23 females, aged 27-81 years old, the onset time of 10 hours to 14 days,

Echocardiography for assessment of left atrial stasis and thrombosis – three cases report

We report three cases of chronic atrial fibrillation without anticoagulation admitted for acute lower limb ischemia in which embolic source was left atrial appendage (LAA) thrombus revealed only by transesophageal echocardiography (TEE). Transthoracic echography (TTE) revealed left atrial dilatation (LA) with no contrast or intracavitary mass. TEE revealed LA with spontaneous echographic contrast, low ostial emptying velocities and congenital morphology of LAA with older and organized thrombus or with echolucent centre (” beard-beark sign of recent and growing thrombus”) and thoracic aorta atheroma plaques. They were discharged on acenocumarol/ novel oral anticoagulant therapy. Two-dimensional echocardiography should be recommended in all patients with periprocedural acute peripheral embolism and TEE only in selected cases. Very high incidence of acute embolic ischemia is probably due to lack of preoperative anticoagulation more than to nontherapeutical anticoagulation (international normalized ratio INR<2).

Abstract O.09: French observatory of Kawasaki disease in adults: 24 observations.

Introduction: Kawasaki disease (KD) is a vasculitis that occurs mostly among children and exceptionally in adults. We report data from a French observatory of adult KD. Patients and methods: Adult patients diagnosed with KD in 16 French centers were included. Patients were classified as complete KD or incomplete KD according to IKDC or probable KD. Results: We included 24 patients with a median age of 29 years (22-39) and a sex ratio (M / F) 2.42, 12 complete KD, 9 incomplete KD and 3 probable KD without any other cause. Time to diagnosis was 13 days (10-20.5). Main events were: fever (100%), extremities changes (21/24, 87.5%), rash (22/24, 92%), conjunctivitis (16/24, 16, 66%), cheilitis (15/24, 63%), strawberry tongue (11/24, 46%), adenopathy (10/24, 42%), cardiac abnormalities (11/24, 46%), cardiogenic shock (n = 1), myo-pericarditis (n = 3) and left heart failure (n = 1). Median CRP was 228mg/L (166-311), SGOT: 68 IU/L (51-139), SGPT: 125 IU/L (69-190), platelets 372 G/L (209-630) and leukocytes 16 G/L (8.3-20). Cardiac involvement was researched in 23 patients (96%) by achieving: echocardiography (20/24), coronary scanners (6/24), coronary angiography (5/24), cardiac MRI (2/24) and stress tests (2/24). An arteritic vascular disease was found in 11 patients (46%): coronary aneurysms (8/24, 33%), coronary arteritis (10/24; 42%) and peripheral arteritis (2/24, 8.3%) with acute lower limb ischemia (1/24, 4.2%) and splenic infarction (1/24, 4.2%). Patients received: intravenous immunoglobulin (17/24; 71%): aspirin (21/24, 88%). After 6 months, it persisted 5 aneurysm (20.8%). Complications noticed during the last follow-up were: heart failure (1/24, 4.3%), aneurysm (3/24, 12.5%). Conclusion: The adult KD is a rare disease that can have bad prognosis in short or long term and leave irreversible damage. The high rate of cardiac complication could be due to the long diagnosis delay, the absence of the gold standard treatment in 30% of cases or a selectional bias due to the difficulty to diagnose this disease in adulthood.

Biomarkers in post-reperfusion syndrome after acute lower limb ischaemia.

Ischaemia reperfusion (I/R) injury refers to tissue damage caused when blood supply returns to the tissue after a period of ischaemia. Matrix metalloproteinases (MMPs), neutrophil gelatinase-associated lipocalin (NGAL) and cytokines are biomarkers involved in several vascular complications. The aim of this study was to evaluate the role of MMPs, NGAL and inflammatory cytokines in I/R syndrome. We conducted an open label, multicentric, parallel group study, between January 2010 and December 2013. Patients with acute limb ischaemia were enrolled in this study and were divided into two groups: (i) those subjected to fasciotomy and (ii) those not subjected to fasciotomy, according to the onset of compartment syndrome. Plasma and tissue values of MMPs and NGAL as well as plasma cytokines were evaluated. MMPs, NGAL and cytokine levels were higher in patients with compartment syndrome. Biomarkers evaluated in this study may be used in the future as predictors of I/R injury severity and its possible evolution towards post-reperfusion syndrome.

Outcome of Early Surgical Intervention in Acute Lower Limb Ischemia due to Thromboembolism

Background: Acute lower extremity ischemia is a common vascular disease and considered limb- and life- threatening. The present study evaluated and compared the outcome of early and late surgical intervention in acute lower limb ischemia due to thromboembolism. Methodology: This non randomized comparative parallel study was conducted at the Department of Cardiovascular Surgery, NICVD, Dhaka, Bangladesh from January 2007 to December 2008 for duration of two year. Total 80 patients were enrolled in this study. The patients were divided into equal two groups, Group A, for early surgical intervention (with in 24 hours) and Group B, late surgical intervention (more than 24 hours). Results: Mean (±SD) age of both Group A and Group B was 51.93 (±11.73) and 47.00 (± 11.01) years. Male and female ratio of the total study population was 1.76:1 Pain and absence of pulse distal to occlusion was common for all. Cold extremity, sensory deficit, motor deficit, diminish vascular flow was the commonest findings of both group. In Group A, 57.5% had superficial femoral artery occlusion, 22.5% had iliac artery and 20.0% popliteal artery occlusion. In Group B, 42.5% had superficial femoral artery occlusion, 32.5% had popliteal artery occlusion and 25.0% had iliac artery occlusion. Fasciotomy was performed in 15.0% patients of Group A and in 22.0% patients of Group B. After Fogarty embolectomy in group A and group B had warm extremity (80.0% vs. 65.0%), pulsation distal to occlusion (90.0% vs. 75.0%), intact sensory function (82.5% vs. 67.5%), intact motor function (80.0% vs. 65.0%), and normal vascular flow by Doppler US (80.0% vs. 65.0%). During postoperative period history of bleeding, infection, reperfusion injury, muscle necrosis and limb amputation were 12.5% vs. 10.0%, 5.0% and 7.5%, 17.5% vs. 35.0%, 15.0% vs. 12.5% and 37.5% vs. 32.5% respectively. Conclusion: Duration of embolism may be the significant factor determining the outcomes of the management of acute arterial embolism in the lower extremities. The 24- hour duration of arterial embolism is a crucial factor influencing the surgical the management and early diagnosis and shifting of patients to specified centre as early as possible to save limb as well as life. DOI: http://dx.doi.org/10.3329/cardio.v7i1.20799 Cardiovasc. j. 2014; 7(1): 38-43

Efficacy of short-term catheter-directed thrombolysis used with rt-PA combined with endovascular interventional therapy in patients with lower limb ischemia

To evaluate the performance effect of short-term catheter-directed thrombolysis with different dosage of rt-PA allied with endovascular interventional therapy for patients with acute lower limb ischemia. To separate 84 consecutive patients suffered from acute lower limb ischemia into two groups at random, then adopt catheter-directed thrombolysis for each group of patients injected 20 mg (Group A) or 10 mg (Group B) rt-PA into the occlusive lesion correspondingly, and subsequently perform endovascular intervention on significant underlying lesions on the base of angiography results. Adopt statistical methods to assess treatment effectiveness, rates of complication and amputation rates within 30 days, 6 months or 12 months. The statistic analysis was performed under SPSS 16.0 format, and adopts t test and χ(2) test. There was no statistical difference on patient characteristics and lesions between both groups (P > 0.05). Procedural success rates as well clinical success rates were all 100%. Not incur any diversity on thrombolysis effectiveness between both groups injected different dosage of rt-PA (P > 0.05). Not found major differences on ratios of PTA or implant stent between both groups (P > 0.05). During the follow-up period of 30-day, 6-, 12- months, there were no statistical differences on the amputation-free survival rates and complication rates between both groups. Whereas short-term catheter-directed thrombolysis combined with endovascular interventional therapy won good operation effectiveness on patients with acute lower limb ischemia, moreover the dosage of rt-PA did not impact on thrombolysis, it is worthy to be applied in the clinical practice.

Acute Gastric Dilatation Causing Acute Limb Ischemia in an Anorexia Nervosa Patient

BackgroundAcute gastric dilatation is a rare but severe complication of anorexia nervosa. Gastric dilatation causing abdominal compartment syndrome with lower-limb ischemia is even less common. This case report illustrates the importance of a holistic clinical approach of every patient presenting to the emergency department (ED), even when the reason for admittance is organ specific. Case ReportWe report the case of a young female patient presenting to the ED with a painful white left leg. Clinical examination revealed acute lower-limb ischemia, abdominal distention, and shock. Diagnostic work-up, including an abdominal computed tomography scan, showed compression of the aorta, inferior vena cava, and both iliac arteries, as well as hypoperfusion of the right kidney and left liver lobe, all due to compression by a massive gastric dilatation. Gastroscopy revealed a massively dilated stomach containing > 6 L of fluid and gastric wall ischemia. After decompression, the circulation to the lower limbs recovered immediately. The day after admission the patient developed an acute abdomen leading to a semi-urgent laparoscopy during which a sleeve gastrectomy was performed for the treatment of partial gastric necrosis. Clinical evolution afterward was favorable and the patient recovered completely. ConclusionsThis case report underscores the importance of a thorough clinical examination in every patient admitted to the ED. Early diagnosis and treatment are mandatory in preventing fatal complications.

Hybrid Revascularization Procedures in Acute Limb Ischemia

Although the clinical efficacy of hybrid procedures in patients with chronic limb ischemia has been well reported in the literature, sufficient evidence is lacking in the acute setting. Our aim was to evaluate the immediate and midterm clinical results on 28 patients with acute lower limb ischemia treated with hybrid reconstructions on emergent basis, from January 2010 to March 2013 in our tertiary referral vascular center. A total of 28 patients (31 operated limbs) underwent emergent hybrid revascularization, with endovascular treatment performed proximally or distally to the site of open reconstruction. The median follow-up period was 6 months (range: 1-26). The immediate technical success was clinically and hemodynamically evaluated with an ankle brachial pressure index (ABPI) measurement. Six-month overall patency, limb salvage, and survival rate were also estimated. All analyses were performed with Kaplan-Meier life table method, using the STATISTICA 7.0 statistical program. Twenty-seven patients presented with grade IIb and 1 with grade III ischemia, respectively. Technical success was achieved in all patients, whereas hemodynamic improvement rate was achieved in 98%. ABPI preoperatively was increased from 0.14 ± 0.1 to 0.69 ± 0.28 postoperatively (P < 0.05). Perioperative morbidity and mortality rates were 21% and 11% respectively. Six-month overall patency, limb salvage, and survival rate were 86%, 92%, and 79%, respectively. Hybrid revascularization in immediately threatened limbs provides an effective and durable option with acceptable mortality and amputation rate in these high-risk patients. These findings should be further confirmed by larger scale clinical studies.

A comparison of umbilical cord blood-derived endothelial progenitor and mononuclear cell transplantation for the treatment of acute hindlimb ischemia

Acute lower limb ischemia is a common peripheral artery disease whose treatment presents many difficulties. Stem cell transplantation is considered a novel and promising method of treating this disease. Umbili- cal cord blood (UCB) is rich in stem cells, including hematopoietic stem cells (HSCs), mesenchymal stem cells (MSCs) and endothelial progenitor cells (EPCs). However, historically, banked umbilical cord blood has been used mainly to treat blood-related diseases. Therefore, this study compared the efficacy of umbilical cord blood- derived mononuclear cells (UCB-MNCs) with EPC transplantation for the treatment of acute hindlimb ischemia (ALI) in mouse models. MNCs were isolated from UCB by Ficoll gradient centrifugation, after which the EPCs were sorted based on CD34+ and CD133+ markers and cultured according to a previously published protocol. To induce ALI, mice were immuno-suppressed using busulfan (BU) and cyclophosphamide (CY), after which the femoral arteries were burned. Induction of ALI in the immune suppressed mice was confirmed by the grade of tissue damage, pedal frequency in water, tissue edema, changes in histology, total white blood cell count, and white blood cell composition. Model mice were injected with a dose of MNCs or EPCs and un-treated control mice were injected with phosphate buffered saline. The efficiency of treatment was evaluated by comparing the grade of tissue damage between the three groups of mice. Mice aged 6-12 months were suitable for ALI, with 100% of mice exhibiting ischemia from grade I 10%, grade III 50%, grade IV 40%. For all ALI mice, a gradual in- crease in pedal frequency in water, increased tissue edema, necrosis of muscle tissue, and loss of hindlimb func- tion were observed after 20 days. Transplanted MNCs and EPCs significantly improved hindlimb ischemia com- pared with control treatment. Moreover, EPC transplantation significantly improved hindlimb ischemia compared with MNC transplantation. Following EPC and MNC transplantation, 44.44% and 33.33% of the mice recovered fully (grade 0), respectively. Specifically, all recovered mice exhibited hindlimb activities similar to those of nor- mal mice. Transplantation of UCB-derived MNCs and EPCs are promising therapies for hindlimb ischemia.

Superior Mesenteric Arterial Embolism Associated with an Acute Limb Ischemia: A Case Report and Literature Review

Introduction: Acute mesenteric ischemia due to an embolism of the superior mesenteric artery (SMA) is associated with a high mortality rate. Over twenty per cent of acute mesenteric embolism cases consist of multiple emboli. Case Presentation: We present a rare case of a 62-year-old man admitted with acute abdominal pain and signs of intestinal occlusion related to an acute mesenteric ischemia due to superior mesenteric arterial embolism. It was associated with a synchronous acute bilateral lower limb ischemia due to embolic arterial occlusion. He underwent an emergency explorative laparotomy with proximal jejunal resection, and the patient made an excellent recovery. As for the acute limb ischemia, it was treated by efficient anticoagulation allowing limb salvage. Conclusion: When treating a superior mesenteric arterial embolism, the possibility of recurrent or multiple arterial thromboembolic events should be considered. A prompt diagnosis, aggressive surgical treatment and intensive care could improve the prognosis.

The combination of surgical embolectomy and endovascular techniques may improve outcomes of patients with acute lower limb ischemia

Surgical arterial thromboembolectomy (TE) is an efficient treatment for acute arterial thromboemboli of lower limbs, especially if a single large artery is involved. Unfortunately, residual thrombus, propagation of thrombi, chronic atherosclerotic disease, and vessel injuries secondary to balloon catheter passage may limit the clinical success rate. Intraoperative angiography can identify any arterial imperfection after TE, which may be corrected simultaneously by endovascular techniques (so-called "hybrid procedures," HP). The aim of this study is to compare outcomes of surgical TE vs HP in patients with acute lower limb ischemia (ALLI). From 2006 to 2012, 322 patients with ALLI were admitted to our department. Patients received urgent surgical treatment using only a Fogarty balloon catheter (TE group = 112) or in conjunction with endovascular completion (HP group = 210). In-hospital complications, 30-day mortality, primary and secondary patency, reintervention rate, limb salvage, and overall survival rates were calculated using the Kaplan-Meier method and compared by log-rank test. HPs (n = 210) following surgical TE consisted of angioplasty (PTA) ± stenting in 90 cases, catheter-directed intra-arterial thrombolysis + PTA ± stenting in 24, thrombus fragmentation and aspiration by large guiding catheter + PTA ± stenting in 67, vacuum-based accelerated thromboaspiration by mechanical devices in 9, and primary covered stenting in 12. Estimated primary patency was 90.4% vs 70.4% at 2-year and 87.1% vs 66.3% at 5-year follow-up, respectively, for HP and TE patients (hazard ratio, 3.1; 95% confidence interval, 1.78-5.41; P < .01). A hazard ratio of 2.1 for limb salvage was noted for the HP group (95% confidence interval, 1.01-4.34; P = .03). Estimated freedom from reintervention at 1 year was 94.4% for HP vs 82.1% for TE patients, and 89% vs 73.7% at 5 years, respectively (P = .04). HPs for ALLI may represent the tools that, when applied to specific clinical scenarios, hold the potential to reduce the morbidity previously associated with acute arterial occlusion.

Independent Factors Predicting Early Lower Limb Intra-arterial Thrombolysis Failure

Risk factors for early catheter-directed intra-arterial thrombolysis failure in acute lower limb ischemia remain unclear. One hundred forty-nine limbs with acute artery or bypass graft thrombosis underwent catheter-directed thrombolysis (maximum of 48 hours). A retrospective data analysis was carried out to assess possible risk factors for early, 30-day treatment failure. Seventy-nine men (53%) and 70 women (47%) with a median age of 70 (range 32-93) years were treated. Treatment outcomes were determined as success (N = 115, 77%) or failure (N = 34, 23%). The failure criteria comprised rapid progression of ischemia (N= 4, 2.7%) and major bleeding complications (N = 2, 1.3%), both requiring thrombolysis termination and surgery. Inability to reopen native arteries/grafts (N = 10, 6.7%), run-off vessels (N = 10, 6.7%), in-hospital death (N = 4, 2.7%), the need for major amputation (N = 13, 8.7%), and reocclusions (N = 5, 3.4%) within the 30-day follow-up period were also considered as failures. Multivariate analysis of the risk factors' impact on the success of thrombolysis revealed such independent parameters as hypercholesterolemia (OR 0.16, 95% CI 0.06-0.42, P < 0.0001), previous bypass grafting of the ipsilateral limb (OR 0.18, 95% CI 0.06-0.53, P=0.002), and duration of ischemia prior to the initiation of thrombolysis (OR 0.95, 95% CI 0.91-0.99, P=0.009, per day). According to our results, factors independently predicting early failure include hypercholesterolemia, previous bypass grafting, and a delay in treatment initiation. Moreover, catheter-directed intra-arterial thrombolysis can be considered safe and effective in the treatment of acute lower limb ischemia.

Characteristics and outcome of patients over 75 years old hospitalized for lower extremity peripheral artery disease in France.The COPART registry

Background: Lower extremity peripheral artery diseases (PAD) is a source of disability and is often associated with other cardiovascular diseases. Large PAD patients registries are very few, particularly with regards to hospitalized patients. PAD prevalence and severity increase with age. However, there are very few data on elderly patients hospitalized for PAD. Our goal was to assess the characteristics and outcome of ≥75-year-old patients hospitalized for a PAD, from the COPART Registry, a prospective multicenter study with patients consecutively recruited from vascular medicine departements of 4 academic hospitals in France between 2006 and 2010. Methods: COPART registry included patients >18 years, with either intermittent claudication associated with an abnormal ABI, and/or an arterial stenosis >50% or ischaemic rest pain, or ulceration and gangrene or acute lower-limb ischaemia. Age threshold was defined at 75 years, and we compared characteristics and outcome between the two groups. * p<0.05 Results: Among the 1,241 patients of the COPART registry, 546 (44%) were ≥75-year-old. They presented less frequenly hyperlipemia (43 vs 62%,*) and active tobacco addiction (50 vs 84%,*) but no difference for high blood pressure or diabetes. They suffered less frequently of AMI (17 vs 24%,*) and COPD (12 vs 16%,*), but more frequently of heart failure (17 vs 9%, p<0.05) and AF (32 vs 11%, p<0.05). The clinical appearances of their PAD were more severe, with arterial ulcers (54 vs 39%,*), ischaemic rest pain (24 vs 35%,*), less intermittent claudication (11 vs 37%,*) but no difference for acute limb ischaemia. Despite similar rate of diabetes between the 2 groups we found significantly more isolated distal lesion (79 vs 52%,*). Therefore more minor amputations were found (11 vs 7%,*) and less bypass surgeries (9 vs 15%,*). The rate of angioplasty and major amputation were similar in both groups. Cardiovascular medical treatments differed only with more VKA (20 vs 13%,*) and less betablockers (22 vs 31%,*). Intrahospital and 1-year mortalites were higher (6.8 vs 2.9%,* and 35.3 vs 13.8%,*) respectively. Conclusion: Patients ≥75-year-old hospitalized for PAD had very poor short and long-term outcome. Most often clinical presentation was advanced critical ischaemia with predominant under-knee artery lesions. These clinical characteristics along with higher cardioembolism risk (AF and heart failure) could explain the low rate of bypass and higher amputation in this population. This result confirms the need to detect PAD in elderly at earlier stage to improve their actual very bad outcome.

Evaluation of Balloon Catheter-Guided Intra-Arterial Thrombolysis for Acute Peripheral Arterial Occlusion

The objective of this study was to evaluate the effectiveness of a new method of in situ thrombolysis using a porous balloon with low pressure compared with traditional in situ infusion of a fibrinolytic agent in the treatment of acute limb ischemia. Between January 2010 and December 2011, 14 patients (mean age, 67.2 years; range, 40-89 years) treated for grade II acute lower limb ischemia for fewer than 14 days were included in the study. Thromboaspiration was tried initially in all the cases. All patients benefitted from a novel method of intra-arterial thrombolysis guided with a balloon catheter (ClearWay; Atrium Medical, Hudson, NH) and using the same agent thrombolytic (Actosolv). The total amount injected, the rate of morbidity associated with the thrombolytic treatment, and the duration of hospitalization in the continuous monitoring unit were analyzed. Recanalization was obtained in 92% of cases (13 of 14). The rate of morbidity related to the procedure was 7%. The amount of fibrinolytic agent necessary was relatively low (82,000 units/cm of occluded artery). The rate of limb salvage 6 months after recanalization was of 92%. The mean duration of stay in the continuous monitoring unit was 1.1 day. Intra-arterial thrombolysis using the ClearWay balloon catheter is an effective method in the treatment of acute peripheral arterial occlusion. In the event of embolic occlusion, mainly among very old patients, it could decrease the hemorrhagic risk. A randomized study in these high-risk patients could confirm these first results.

Acute Peripheral Arterial Occlusion: Prospective Study Evaluating Intra-Arterial Thrombolysis With a Micro-Porous Balloon Catheter

To assess the efficacy of a new in situ thrombolysis method using a low-pressure micro-porous balloon catheter (MPBC) compared to a traditional in situ infusion (ISI) of a fibrinolytic agent in the treatment of acute limb ischemia. Between January 2010 and December 2011, 21 patients (14 men; mean age 64.6 years, range 40-92) treated for acute lower limb ischemia were prospectively enrolled in the study. Seven patients underwent in situ thrombolysis using the ISI method and 14 patients the MPBC method to deliver urokinase. The total urokinase dose injected and the length of stay in an intermediate care unit were compared between the groups. Recanalization was successful in 90% of cases (6/7 patients in the ISI group; 13/14 patients in the MPBC group). The morbidity was 7% (1 pseudoaneurysm). The dose of urokinase needed was significantly lower (p<0.001) in the MPBC group (0.7±0.44 IU, range 0.15-1.6) vs. the ISI group (1.66±0.71 IU, range 0.2-2). The average length of stay in the intermediate care unit was significantly shorter in the MPBC group (1.2 vs. 3.9 days, p<0.002). The overall 6-month limb salvage rate after recanalization was 90% (83% for the ISI patients vs. 93% for the MPBC group). Intra-arterial thrombolysis using a balloon catheter is an effective method in the treatment of acute peripheral arterial occlusions. In the case of occlusion caused by embolism, primarily in very elderly patients, it may reduce the risk of hemorrhage. A randomized study on high-risk patients is needed to confirm these initial results.

Safety and Efficacy of Ultra-high-dose, Short-term Thrombolysis with rt-PA for Acute Lower Limb Ischemia

The evaluation of success and complication rates of ultra high-dose recombinant tissue plasminogen activator (rt-PA) administered over a short time frame in the treatment of acute lower limb ischemia. This was a prospective single-center study. The outcome of treatment in 97 patients with acute limb ischemia (<14 days) with the use of catheter directed rt-PA infusion was evaluated. The mean total dose of rt-PA was 54.1 mg (50-60 mg) and was administered for a mean of 2.51 hours (2-4 hours). Thrombolytic success was defined as 95% thrombolysis of an occluded segment with return of antegrade flow. Thirty-day complication and amputation-free survival rates were calculated. Thrombolytic success was achieved in 83.5%. Overall clinical success was 88.7%. The 30-day amputation-free survival rate was 93.8%. Major bleeding complications occurred in 10 patients (10.3%). There were two deaths (2.1%) and four amputations (4.1%). Long-term amputation-free survival was 70%. Administration of ultra-high doses of rt-PA over a short time period gives promising results. Such delivery improves patient tolerance by rapid restoration of limb perfusion; however further studies are required to confirm these results.

Role of the femorofemoral crossover graft in acute lower limb ischemia due to acute type B aortic dissection

Acute limb ischemia due to type B aortic dissection is rare and continues to be a management challenge. A case series is presented here with the aim of assessing the outcomes of treatment with a femorofemoral crossover graft with or without thoracic stent graft insertion. This is a combined retrospective and prospective review of nine cases of acute lower limb ischemia secondary to acute type B aortic dissection. The presenting features, radiological findings, treatment and outcomes were reviewed. Five patients had a femorofemoral crossover graft (FFXO) alone, two an FFXO with a thoracic stent graft and the eighth a thoracic and iliac stent. The other case was initially treated conservatively but subsequently required an FFXO. The mean follow-up was 16 (3-51) months. A further two thoracic stents were placed during the follow-up period. Thus five out of nine patients (56%) required aortic stenting. This series suggests that an FFXO is a reliable treatment for acute limb ischemia due to type B aortic dissection. However, these patients are often complex with ischemia in other vascular beds and are at risk of subsequent aneurysmal dilation.