Infrainguinal Region Research Articles

Anatomic evaluation to compare the dye spread with ultrasound-guided pericapsular nerve group (PENG) injection with or without an additional suprainguinal fascia iliaca (SIFI) injection in soft embalmed cadavers.

Novel interfascial plane blocks like PEricapsular Nerve Group (PENG) and SupraInguinal Fascia Iliaca (SIFI) blocks are effective for management of hip fracture pain. We compared the difference in the distribution of the dye injected and nerves stained by the addition of the SIFI block to the PENG block. A total of 24 designated dye injections were performed in eight soft-embalmed cadavers. Under ultrasound guidance 20ml green ink injected bilaterally in PENG block and 30ml methylene blue dye was injected in the SIFI block on the right side. The cadavers were dissected 24h later to assess the extent of dye spread. Extensive spread of dyes was seen on both side of iliacus muscle on the right side, but blue dye was not visible medial to the psoas tendon. The subcostal and iliohypogastric nerves were stained green in the infra-inguinal region. On the left side (PENG alone), the anterior division of the obturator, femoral and saphenous nerve (7/8) and iliohypogastric nerves (3/8) were stained in the infrainguinal region. In the suprainguinal region, the femoral nerve (5/8), accessory obturator nerve (3/8), lateral femoral cutaneous (1/8) and nerve to rectus femoris (4/8) were stained. The main obturator nerve trunk was spared with both injections while its anterior branch and accessory obturator nerve were stained with the PENG injection. The study findings indicate that combined PENG + SIFI injections lead to an extensive craniocaudal and longitudinal spread along the iliacus muscle. We perceive that the combination of these two injections will have a superior clinical outcome.

Paradigm shift in the vascular surgery of the lower extremity at the Department of Vascular Surgery, University of Szeged, Hungary

Endovascular interventions were initially performed by radiologists. Nowadays properly trained vascular surgeons also effectively perform these interventions. We wished to apply this widespread practice at our university because without this advancement the number of reconstructive surgeries was expected to decrease significantly. Both radiologists and vascular surgeons perform endovascular interventions at our university. We compared the outcomes of lower extremity endovascular interventions between the two institutes. We included patients who underwent lower extremity endovascular interventions between 01. 01. 2012 and 31. 12. 2019. We compared the risk factors, treated anatomical regions, hospitalization time and complication rate. During the one-year follow-up, we examined the occurrence of redo surgeries, amputations and mortality. 653 interventions were performed by radiologists and 573 by vascular surgeons. Vascular surgeons carried out more interventions in the infrainguinal region (63.2%), while radiologists in the suprainguinal region (68.6%). The hospitalization time after percutaneous interventions (2.5 ± 4.4 days vs. 2.4 ± 2.5 days, p = 0.78), and the rate of complications after minimally invasive interventions did not show significant difference (30/653 - 4.6% vs. 11/257 - 4.3%, p = 0.837). Redo surgeries (73/485 - 15.1% vs. 33/562 - 5.9%, p<0.001) and amputations (31/485 - 6.4% vs. 12/562 - 2.1%, p<0.001) occurred more frequently in the surgical group. However, the incidence of chronic limb ischaemia was also higher (45.4% vs. 38.6%, p = 0.016). There was no significant difference in the mortality (5.8% vs. 3.9%, p = 0.16). Both institutes had similar efficacy in performing peripheral interventions on solitary vascular lesions. Complications occurred more frequently in the surgical group, but the majority of these patients had extended atherosclerotic diseases. Orv Hetil. 2021; 162(24): 943-951.

Fat-suppressed magnetic resonance volume interpolated examination for deep venous thrombosis compared with duplex sonography.

The aim of the present study was to evaluate magnetic resonance venography (MRV) scanned by breath-hold volume interpolated body examination with spectral fat saturation (VIBE-fs), combined with Dixon fat-suppressed VIBE (VIBE-Dixon) by using a 1.5T MR scanner for detecting deep venous thrombosis (DVT) compared with duplex sonography. A total of 31 patients with DVT were identified using duplex sonography and were enrolled in the present study for MRV examination, from the inferior vena cava to the ankle level after injection of gadopentetate dimeglumine. Venous segment-to-segment comparison was assessed for DVT detection between MRV and duplex sonography. A total of two radiologists separately performed subjective image quality assessment using a 5-point scale. Cohen's κ coefficient, Wilcoxon rank sum test and intraclass correlation coefficient values were used for statistical analysis. Of the 303 evaluated vein segments, duplex sonography identified 119 (39.3%; 119/303) venous segments with thrombus, while MRV detected 170 (56.1%; 170/303) venous segments with thrombus. The diagnostic agreement rate of DVT between duplex sonography and MRV was poor in the deep femoral vein and anterior tibial veins, while it was excellent in the inferior vena cava (IVC), common iliac vein, external iliac vein, femoral vein, popliteal vein, posterior tibial veins and peroneal veins. In addition, poor reliability was detected in the deep femoral vein, anterior tibial veins and peroneal veins, but good to excellent reliability was observed in IVC, common iliac vein, external iliac vein, femoral vein, popliteal vein and posterior tibial veins. Furthermore, image quality scores of each venous segment between the two radiologists indicated no statistical difference. Therefore, MRV scanned using VIBE-fs for the suprainguinal and VIBE-Dixon for the infrainguinal region may be a useful method for detecting DVT compared with duplex sonography. The results of present study proved this MR protocol to be a beneficial alternative imaging modality for the detection of DVT when duplex sonography is inadequate or not able to be performed.

Occlusive Lower-extremity arterial disease: clinical setting and diagnostic imaging

Background: The clinical diagnosis of occlusive lower extremity arterial disease (OLEAD is usually clear but certain investigations are needed to confirm the diagnosis and determine extent and severity of the disease for treatment plans. A diagnosis of OLEAD mandates a comprehensive approach involving justification of the clinical features and imaging facilities. Objectives To assess diagnostic accuracy of occlusive lower extremity arterial disease that was based on clinical approach and to compare vascular imaging in Doppler Duplex with CT 64-Multislice Detector Angi. ography. Materials and methods. The study included 53 patients who were admitted in the surgical ward for evaluation and treatment of lower extremity arterial disease from January 2009 through June 2009. Clinical assessment, Doppler Duplex and CT angiography was performed for all patients. Doppler Duplex reports and CT images were compared to determine the extent of the occlusive process. ResultsThere were 41 male and 12 female patients. Pre Imaging clinical diagnosis was determined in all patients. Doppler Duplex was a useful diagnosis of femoropopliteal disease but not in aortoiliac disease. CT angiography was helpful in the diagnosis of aortoiliac disease. It was also helpful in determining the extent of femoropopliteal disease and assessment of collateral circulation. Conclusion: A combination of clinical assessment, Doppler Duplex and CT angiography is necessary for perfect diagnosis and planning of treatment. Doppler Duplex in expert hands is a useful modality for estimation of a diseased segment in the infrainguinal region but not for aorta iliac arteries.

The added benefits and efficacy of atherectomy in the lower limb.

Atherectomy has been used as an adjunct therapy for balloon angioplasty and/or stent placement in the superficial femoral artery for many years, but has never gained global popularity in the treatment of peripheral arterial disease, most probably related to the conflicting results as published in the literature. Novel techniques that have been developed over the past years are yielding promising results in the infrainguinal region. This paper will describe the added benefits of atherectomy as compared to plain old balloon angioplasty and bail-out bare-metal stenting, both in the treatment of primary lesions of the superficial femoral artery as well as in cases of in-stent restenosis.

Segmental Comparison of Peripheral Arteries by Doppler Ultrasound and CT Angiography

Diseases of peripheral arterial system are one of the common causes of limb pain, especially in elderly patients. Here we analyse non invasive imaging of peripheral arterial segments. Aim of the study was to compare arterial diseases of extremities using Doppler ultrasound and CT angiography, and to find the better non-invasive modality of choice. Fifty patients {14 patients with upper limb complaints (15 upper limbs) and 36 patients with lower limb complaints (72 lower limbs)} of peripheral arterial disease underwent Doppler ultrasound (USG) and CT Angiogram (CTA). Arterial systems divided into anatomic segments and luminal narrowing were compared using gray scale Doppler ultrasound and axial images of arterial phase of CT angiogram. Using statistical methods, sensitivity, specificity and accuracy of Doppler ultrasound and CT angiography were determined. Six hundred and nineteen arterial segments were studied with CT angiography and Doppler ultrasound. Of which 226 diseased segments were identified in CT angiography. Doppler overestimated narrowing by one grade in 47 segments, by two grade in 11 segments, by three grades in 30 segments and by four grades in 22 segments; underestimated by one grade in 28 segments, by two grades in 9 segments, by three grades in 5 segments and by four grades in 3 segments. Significant statistical difference exists between Doppler USG and CT angiography. Doppler showed good correlation with CT angiography in 74%, but, Doppler overestimated stenosis grade in a significant percentage. The sensitivity, specificity and accuracy of Doppler USG compared with CT angiography was 93.36%, 82.44%, and 86.42%. Duplex Doppler can be the first investigation in excluding peripheral arterial disease, especially for evaluation of infra inguinal region of lower limbs and from second part of the subclavian artery in upper limbs.

A practical approach to the lateral cutaneous nerve of the thigh: An anatomical study

Objectives To study the main anatomical landmarks related to the lateral cutaneous nerve of the thigh (LCN) in the infrainguinal region and to define reliable criteria for identifying the nerve during the surgery and electrophysiological study. Methods Bilateral dissections of 60 adult non-fixed cadavers were performed with measurements of the distance between the inferior border of the anterior superior iliac spine (ASIS) and the LCN (DAL) and the internal angle between the LCN and the inguinal ligament (IA). The number of nerves exiting the inguinal ligament, the position of the LCN relative to the ASIS and to inguinal ligament were observed and registered. A triangle was designed using the inguinal ligament, the ASIS and the direction of tendinous insertions of the tensor of fascia lata muscle as parameters and the nerves were tested according its localization inside the triangle in each dissection. Results In 80% of the dissections, the LCN passed under the inguinal ligament and was identified lateral to ASIS in only three dissections. A great variability was observed in the values of DAL and IA. The values of DAL ranged from 0 (immediately medial to ASIS) to 5 cm on either side with means of 1.31 and 1.22 cm on the right and left side, respectively. The values of IA ranged from 40° to 120°, with a mean of 66.08° on the right side and from 40° to 130° with a mean of 69.92° on the left side. No significant differences were identified between the two sides with respect to the relationship between the nerve and the inguinal ligament (Chi-square test, p = 0.83); DAL ( t test, p = 0.37) or IA ( t test, p = 0.15). A single nerve was found in 70.83% of the dissections. The nerve was found inside the triangle in 95% of the dissections. Conclusions Despite the symmetry found between the right and left sides, the values of the main anatomic parameters involved in the localization of the LCN presented a great degree of variability. Even so, dissection using the proposed anatomical triangle allows for the localization of the LCN in almost all cases.

Periphere arterielle Verschlusskrankheit und akute Extremitätenischämie

In this article, current evidence-based treatment recommendations for acute and chronic lower limb ischemia will be presented considering the varied possibilities of endovascular techniques and open surgical vascular strategies. Beside presentation of the different therapeutic possibilities, advantages of the combination of both techniques will be described. Despite the BASIL trial, there are no prospective randomised controlled trials comparing endovascular and open surgical interventions. Different therapeutic rules along the different vascular segments will be discussed for both acute and chronic peripheral arterial disease. Generally it can be stated that aortoiliac revascularization for chronic obstructions is increasingly being carried out by endovascular means or hybrid procedures using a minimally invasive femoral approach, whereas acute occlusions in this vascular segment are still treated with open surgical techniques (Fogarty balloon thrombectomy). In the infrainguinal region, endovascular therapeutic strategies are gaining favor. However, multilevel occlusions and long-segment obstructions in the femoral and popliteal segment are still treated by bypass procedures. Acute ischemia in the infrainguinal segment is increasingly treated with endovascular methods (local thrombolysis and percutaneous thrombectomy).

Long-term outcome after surgical treatment of arterial lesions in Behçet disease

Surgical treatment of arterial lesions associated with Behçet disease (BD) is often complicated by graft occlusion and recurrence of aneurysms. The purpose of this study was to clarify the long-term outcome of surgical intervention for arterial involvement in BD. Ten patients with BD (9 men, 1 woman) who underwent surgical treatment for arterial aneurysms between 1980 and 2004 were included in the study. The age of patients at the first operation ranged from 36 to 69 years (mean, 50.4 +/- 9.0 years). The mean period between the onset of BD and that of arterial manifestations was 8.0 +/- 5.0 years. We retrospectively reviewed their postoperative courses, including survival, graft occlusion, formation of anastomotic false aneurysms, and the development of aneurysms at different sites. The Kaplan-Meier method was used to calculate the chronologic incidence of complications after surgery. The mean follow-up period was 133 +/- 92 months, ranging from 5 to 285 months. One patient died of rupture of a dissecting aortic aneurysm after undergoing several surgical interventions for multiple aneurysms. There were five graft occlusions among 21 grafts. The cumulative primary graft patency rate in the infrainguinal region was 83.9% at 3 years. Five anastomotic false aneurysms formed among 49 anastomoses between grafts and host arteries. The overall cumulative incidence of formation of anastomotic pseudoaneurysm was 12.9% at 5 and 10 years. All of them formed within 18 months after surgery. Development of new aneurysms in different arteries was observed in two patients. Early occurrence of anastomotic false aneurysm is characteristic of BD. Further investigation is necessary to establish effective postoperative treatment.

Arterial Perforation (by Balloon) During Subintimal Angioplasty

Perforation complicates 3–4% of angioplasties and can be treated by temporary balloon occlusion, coil embolisation, placement of a covered stent or redissection past the perforation using the subintimal angioplasty technique. Our unit has generally been reluctant to place covered stents in the infra-inguinal region, largely because of concerns about in-stent restenosis. Most perforations occurring during subintimal angioplasty (a modification of the traditional angioplasty technique) follow manipulation of the guide wire in the extra-luminal space. A relative minority occur during balloon inflation. It has previously been our experience that arterial perforation does not worsen outcome following angioplasty and we have, therefore, never recommended post-procedural ultrasound surveillance. We report a case of a successfully treated perforation occurring during subintimal angioplasty. The perforation occurred during balloon insufflation of the subintimal channel and then presented secondarily with a large, symptomatic false aneurysm. Awareness of this case has led to a revision of our post-procedural surveillance strategy.

Approach to vascular access for hemodialysis: experiences from the Republic of Macedonia.

Eight thousand eight hundred and forty nine different vascular hemodialysis accesses were performed in the period from 1976 until 1999 at the Department of Nephrology, Skopje: 3,114 native arterial-venous fistula (AVF), 715 arterial-venous shunts (AVS), 4,964 temporary or permanent catheters (4,411/88.86% femoral, 410/8.26% subclavian, 143/2.88% jugular) and 56 PTFE vascular grafts. Femoral catheterization (4,312/86.86%) is the favoured solution if a temporary vascular dialysis access is taken into consideration. The most popular chronic dialysis angio-access in our country is native AVF (90.5% of 3,440 permanent dialytic vascular accesses). The tunneled subcutaneously positioned catheters as a permanent dialytic angio-access were present in 270 cases (7.9%): 99 in femoral veins (our original method), 123 in subclavian veins and 48 catheters in jugular veins. The synthetic vascular grafts-PTFE (polytetrafluoro-ethylene) represent only 1.6% of all dialysis angio-accesses. The number of preventive AVFs created in patients with preterminal end-stage renal disease eventually increased; from 14% in the eighties, 20.8% after 10 years and 31.50% in 1999. Most of the preventive AVFs are done in outpatients 71.8% in 1999. This year 44.4% of all chronic vascular access were created in the same way. We prefer femoral catheters for both temporary and permanent access because our results show that femoral catheterization has a lower rate of early complications when compared to the subclavian catheterization group; the rate of late complications (thrombosis, stenosis, infections) is lower or the same; infections in femoral catheterizations are less frequent, compared to subclavian and jugular ones. Our contributions in the field of vascular access surgery are the three original methods which are constantly used at the Department: 1. Combination of temporary (AVS) and permanent vascular access (AVF) using the same blood vessels, performed in one surgical act; 2. Tunneled femoral catheter as a permanent vascular access for hemodialysis (2 types: on the abdominal wall and on the infrainguinal region - thigh); 3. Reduction of hyper-flow in AVF without the operation of "banding", with ligation of the artery before arteriovenous anastomosis.

Comparison of the long-term results between surgical and conservative treatment in patients with intermittent claudication

The optional therapeutic strategy for patients with intermittent claudication remains controversial. In this study, we investigated the influence of surgical and conservative therapies on improving the quality of life in patients with intermittent claudication. We analyzed 427 patients who were admitted to our hospital with intermittent claudication in their legs during a 15-year period from January 1984 to December 1999. We separated them into 2 groups; 259 patients (362 legs) were treated surgically and 168 patients were treated conservatively. At the suprainguinal and infrainguinal (above knee) region, the surgery group showed significantly better rate of improvement than did the conservative group, but in the infrainguinal (below knee) region, there was no significant difference between the 2 groups. The 3-year and 5-year patency rates for the arterial reconstruction of the suprainguinal and infrainguinal region was satisfactory, but that of the infrainguinal region was not very good even if an auto vein graft was used. Aggressive surgical treatment is therefore recommended in patients whose distal anastomotic region is above the knee, because there are great benefits from surgical reconstruction. However, in patients whose distal anastomotic region is below the knee, conservative treatment might be just as effective as surgery.

Prospective Comparison of MR Phase-Contrast Velocimetry with Intravascular Doppler US during Infrainguinal Artery Angioplasty

To evaluate the accuracy of magnetic resonance (MR) velocimetry for quantitative assessment of stenosis in patients undergoing percutaneous transluminal angioplasty (PTA). Thirty patients underwent PTA of the infrainguinal region. To assess hemodynamic parameters of lesions, MR phase-contrast velocimetry with a circular-polarized extremity receiver coil and a cardiac gated gradient echo sequence was conducted before and 1 day after PTA. Additionally, all lesions were examined by means of intravascular Doppler flow measurements (0.018-inch wire, 12 MHz). From these data, the degree of stenosis was calculated and a comparison of MR velocimetry with intravascular Doppler US was undertaken. Correlation between calculated grade of stenosis for MR velocimetry and intravascular Doppler US was good and significant (r = 0.74; P <.001). Calculated luminal stenosis grade were similar for both methods before PTA (intravascular Doppler US: 0.62 +/- 0.18, MR velocimetry: 0.54 +/- 0.19; P =.17 with paired Student t-test) and after PTA (0.25 +/- 0.23 and 0.3 +/- 0.2, respectively; P =.56). MR velocimetry results in reliable noninvasive in vivo flow measurements and allows accurate assessment of stenosis in a clinical setting.

Management of Vascular Prosthetic Infections: Results of Long-Term Follow-up

An infected vascular prosthesis is a risk to life and limb, with many of the infections insidious in nature. A retrospective analysis with a minimum 49-month follow-up identified 18 patients (mean age, 61.3 years) with culture-positive infections and exposed prosthetic grafts in the infrainguinal region. All patients were managed with muscle flaps. Mean follow-up was 59 months, with a long-term salvage of infected prosthetic grafts in 16 of 18 patients; there was no loss of life or limb. Early, aggressive reconstruction of infected prosthetic grafts using a muscle flap technique saves graft, leg, and patient.

Arterial reconstruction: justified for patients with intermittent claudication?

The objective of this study was to evaluate the effects of arterial reconstruction in patients with intermittent claudication. A total of 243 patients (305 limbs) underwent lower extremity vascular reconstruction at our institution from 1979 to 1995. They were assessed by physical examination, pulse volume recordings, segmental pressure, Duplex ultrasonography, and intravenous subtraction arteriography to evaluate the effects of arterial reconstruction. Surviving patients (220 limbs) were enrolled for evaluation of outcome during the follow-up period. There were 59 deaths during the follow-up period. The cumulative life-table 5-year patency rates were 90% +/- 3%, 73% +/- 6%, and 74% +/- 10% for aortoiliac, infrainguinal, and aortofemorodistal arterial reconstructions, respectively. Among 129 repairs in the aortoiliac region, Fontaine stages I, II, and III were found in 109 limbs (84.5%), 17 limbs (13.2%), and 2 limbs (1.5%), respectively. There was one (0.7%) minor amputation. There was Fontaine stage I in 50 limbs (76.9%), Fontaine stage II in 14 limbs (21.5%), and Fontaine stage III in 1 limb (1.5%) for repairs in the infrainguinal region. Among the 26 aortofemorodistal repairs, there was Fontaine stage I in 21 limbs (81%) and Fontaine stage II in 5 limbs (19%). There was a statistically significantly higher incidence of Fontaine stage I than Fontaine stage II or III in aortofemoral, infrainguinal, and aortofemorodistal arterial reconstructions (p < 0.0001). Arterial reconstruction for patients at Fontaine stage II offered benefits and improved quality of life at follow-up. Arterial reconstruction for patients at Fontaine stage II offers benefits and improved quality of life at follow-up. It was concluded that the significant improvement in quality of life after arterial reconstruction warrants continued use of the procedure in patients with intermittent claudication.