Leg Ischemia Research Articles

Abstract 14158: Ankle-brachial Index and Risk of Severe Ischemic Leg Outcomes in a Community-based Population: The Atherosclerosis Risk in Communities (ARIC) Study

Introduction: Ankle-brachial index (ABI) ≤ 0.9 is used to define lower-extremity peripheral artery disease (PAD). However, the association between ABI and severe ischemic leg outcomes in the general population has not been investigated. Hypothesis: Lower ABI is independently associated with risk of severe ischemic leg outcomes. Methods: We studied 13,742 ARIC participants (median age 54 [SD 5.75] years, 45% males) without intermittent claudication or a history of revascularization for PAD at baseline (1987-89). We quantified the association of ABI with risk of severe ischemic leg outcomes using Cox regression. ABI was modeled as a restricted cubic spline allowing for potentially non-linear associations. Severe ischemic leg outcomes were ascertained through ICD codes and included critical limb ischemia (CLI) (defined as PAD with rest pain or tissue loss) and ischemic leg amputation (amputations with PAD diagnosis). Results: Over a median of 28 years of follow-up, there were 221 and 129 events of CLI and ischemic leg amputation, respectively. Lower ABI was linearly associated with both CLI and ischemic leg amputation (Figure). With ABI 1.25 as the reference, adjusted hazard ratios of CLI were 2.48 (95% CI 1.15-5.36) at ABI 0.7, 1.97 (1.30-2.99) at ABI 0.9, and 1.73 (1.18-2.54) at ABI 1.0. The corresponding hazard ratios of ischemic leg amputation were 3.57 (1.44-8.81), 2.63 (1.54-4.48), and 2.23 (1.34-3.70), respectively. The association was largely consistent in demographic and clinical subgroups, although the results were less evident in younger and female participants compared to their counterparts. Conclusions: In middle-aged adults without clinical PAD, lower ABI was independently and linearly associated with higher risk of severe ischemic leg outcomes. Our results support the value of ABI as an indicator for leg vascular condition and also indicate that ABI 0.9-1.1 should not be considered normal for ischemic leg prognosis.

Abstract 15182: Acute Complications of Type B Aortic Intramural Hematoma Compared With Classic Aortic Dissection

Introduction: Although acute type B aortic intramural hematoma (B-IMH) is a variant of acute aortic syndrome having similar clinical demographics to type B classic aortic dissection (B-AD), early clinical course including acute complications are not well investigated. The purpose of this study was to investigate early clinical course and acute complications of B-IMH in comparison with that of B-AD. Methods: Clinical features and early clinical course including acute complications were retrospectively analyzed in 270 B-IMH and 177 B-AD consecutive patients who were admitted to our hospital between 1991 and 2020. Acute complications were defined as rupture, impending rupture, re-dissection, and visceral and leg ischemia. Results: As compared with B-AD, B-IMH presented at older age (72±11 vs 62±15 years; p<0.001), predominantly in females (37% vs 25%). During in-hospital courses, limb ischemia and mesenteric ischemia were less common in patients with B-IMH than those with B-AD (0.4% versus 5.1%, p=0.003, 0.4% versus 2.8%, p=0.03; respectively). In contrast, spinal ischemia was more common in B-IMH patients (2.4% versus 0.6%, p=0.05). Aortic rupture and impending rupture were comparable between B-IMH and B-AD patients (5.9% versus 7.3%. p=0.28). Besides, re-dissection was also comparable between two groups (2.2% versus 5.1%, p=0.06). As a result, prevalence of acute complications was significantly lower in patients with B-IMH (8.8% versus 17%, p=0.008). In-hospital mortality rate in B-IMH was significantly lower than that in B-AD (0.4% versus 9.0%, p<0.001). Conclusions: Although patients with B-IMH had lower in-hospital mortality rates than patients with B-AD, significant portion of B-IMH patients had fatal complications including spinal ischemia or aortic rupture. Patients with B-IMH should be carefully observed as well as patients with B-AD patients.

Abstract 15252: Ischemic-Trained Monocytes Improve Arteriogenesis During Hindlimb Ischemia

Introduction: Recent studies have shown that innate response can build immunological memory. This process called “trained immunity” is an epigenetic reprogramming of the monocytes driven by a metabolism shift towards glycolysis. Hypothesis: Since HIF-1a is a major player in monocytes activation and also targets some epigenetic enzymes, we hypothesize that hypoxia/ischemia can lead to “trained immunity” improving arteriogenesis in a mouse model of hindlimb ischemia. Methods: Mice subjected to a unilateral single ischemia insult for 24hours (24h group: femoral artery ligation for 24 h) or by ischemia reperfusion cycles (Cycle group: ischemia-reperfusion in 4 cycles of 5 minutes) or non-ischemia (sham group), were used as donors in the monocyte transfer experiment. Recipient mice underwent to permanent hindlimb ischemia one day prior the tail vein injection of bone marrow (BM) monocytes from the ischemic leg. Laser Doppler assessed blood flow recovery before and after hindlimb ischemia. Arteriogenesis was quantified on recipient mice by assessing the diameter of gracilis collaterals. A 24h group monocytes from ischemia and non-ischemia leg was used as donors to test the systemic vs. local effect of the ischemic-trained monocytes. Lin- cells were used as a control. Cultured human monocytes were subjected to 24h hypoxia and gene expression for epigenetic enzymes was performed by real time rt-PCR Results: Blood flow recovery in recipients who received ischemic-trained monocytes (24h and cycle) improved overtime compared to sham. Arteriogenesis was significant greater in 24h group compared to sham. Surprisingly, the improvement in blood flow recovery was abolished using combined monocytes from ischemic and non-sichemic, suggesting that ischemia training has a local effect in the monocytes. The Lin- experiment confirmed that the ischemia training is monocyte specific. Moreover, hypoxia regulated epigenetic enzymes responsible for histones methylation in human monocytes. Conclusions: Monocytes can be trained by previous ischemia/hypoxia insult and improve arteriogenesis during hindlimb ischemia. The molecular mechanisms that lead the trained immunity by hypoxia still unknown, however epigenetic modifications might play a role in this process.

Abstract 12624: Pathological Analysis Reveals Causes of Poor Patency After Endovascular Therapy for Below-the-knee Lesions

Introduction: Endovascular therapy for below-the-knee (BTK) lesions often ends in unsatisfactory outcomes not only by balloon angioplasty (BA) alone but also by adding drug-eluting stent (DES) implantation to BA. We assessed the hypothesis that a histopathological analysis of the amputated tissues would reveal the causes of poor patency after BTK endovascular therapy. Methods: We examined tissue specimens from BTK lesions obtained by surgical resection after BA alone (n = 15) and after BA and DES implantation (n = 9). All of them were 100 mm or more in length and had rapid worsening of distal leg ischemia within three months after successful revascularization. More than 60% of them had chronic total occlusion. DESs for coronary arteries of similar sizes were repurposed and used for BTK arteries (drug type: everolimus; size: 2.5-3.0 mm х 28-38 mm). Results: Histologically, severe atherosclerosis and intimal-medial calcification were observed in all specimens. Many cases treated by BA alone suffered large semilunar dissection caused by guide-wire failure via the true lumen. There were cases where initial luminal expansion was impaired by vessel shrinkage, in which significant intimal-medial disruption, medial dissection, and massive thrombus formation were observed. Also, there were cases where remarkable lumen loss was caused by neointima formation with a considerable amount of smooth muscle cells and proteoglycan. All cases treated by BA and DES implantation suffered total lumen occlusion due to thrombi which were organized by moderate smooth muscle cell proliferation. Their proximal edge segments had moderate to severe intimal hyperplasia caused by balloon dilatation. Three DESs implanted in the middle portion of the BTK lesions were markedly deformed under compression by the surrounding muscles. Conclusions: After BTK endovascular therapy, cases treated by BA alone had poor patency due to insufficient luminal expansion, whereas those treated by BA and DES implantation had organized thrombus formation caused by slow and limited flow inside the DES due to intimal hyperplasia in the proximal segment. Smooth muscle cell proliferation inside the DES may be inhibited by the effect of the drug coated on the DES.

Comparison of mechanical circulatory support with venoarterial extracorporeal membrane oxygenation or Impella for patients with cardiogenic shock: a propensity-matched analysis

BackgroundPercutaneous mechanical circulatory devices are increasingly used in patients with cardiogenic shock (CS). As evidence from randomized studies comparing these devices are lacking, optimal choice of the device type is unclear. Here we aim to compare outcomes of patients with CS supported with either Impella or vaECMO.MethodsRetrospective single-center analysis of patients with CS, from September 2014 to September 2019. Patients were assisted with either Impella 2.5/CP or vaECMO. Patients supported ultimately with both devices were analyzed according to the first device implanted. Primary outcomes were hospital and 6-month survival. Secondary endpoints were complications. Survival outcomes were compared using propensity-matched analysis to account for differences in baseline characteristics between both groups.ResultsA total of 423 patients were included (Impella, n = 300 and vaECMO, n = 123). Survival rates were similar in both groups (hospital survival: Impella 47.7% and vaECMO 37.3%, p = 0.07; 6-month survival Impella 45.7% and vaECMO 35.8%, p = 0.07). There was no significant difference in survival rates, even after adjustment for baseline differences (hospital survival: Impella 50.6% and vaECMO 38.6%, p = 0.16; 6-month survival Impella 45.8% and vaECMO 38.6%, p = 0.43). Access-site bleeding and leg ischemia occurred more frequently in patients with vaECMO (17% versus 7.3%, p = 0.004; 17% versus 7.7%, p = 0.008).ConclusionsIn this retrospective analysis of patients with CS, treatment with Impella 2.5/CP or vaECMO was associated with similar hospital and 6-month survival rates. Device-related access-site vascular complications occurred more frequently in the vaECMO group. A randomized trial is warranted to examine the effects of these devices on outcomes and to determine the optimal device choice in patients with CS.

Axillary artery cannulation for veno-arterial extracorporeal membrane oxygenation support in cardiogenic shock.

ObjectiveTo review the outcomes of axillary artery (AX) and femoral artery (FA) cannulation for veno-arterial extracorporeal membraneous oxygenation (VA-ECMO).MethodsFrom 2009 to 2019, 371 patients who were supported with VA-ECMO for cardiogenic shock were compared based on the arterial cannulation site: AX (n = 218) versus FA (n = 153).ResultsPatients in the AX group were older (61 years vs 58 years, P = .011), had a greater prevalence of peripheral vascular disease (13.8% vs 5.2%, P = .008), and were less likely to have undergone cardiopulmonary resuscitation preoperatively (18.8% vs 36.6%, P < .001). Other characteristics were similar between groups, as were in-hospital outcomes, including survival to discharge (60.6% vs 56.9%), cerebrovascular accidents (12.4% vs 10.5%), cannulation-related bleeding (15.1% vs 17%), and length of VA-ECMO support (6 days). The incidence of leg ischemia (6.9% vs 15.7%, P = .006), limb ischemia related to VA-ECMO cannulation (0% vs 10.5%), the need to switch the cannulation site (4.6% vs 14.7%), and wound complications (WCs; 2.8% vs 15%) including infection and additional procedure were significantly greater in the FA group (P < .001). In multiple logistic regression analysis, FA cannulation and primary graft failure after heart transplantation were independent risk factors for cannulation-related WC. In subgroup analysis among patients with primary graft failure, WCs were more prevalent in FA cannulation (3.6% vs 39.1%, P = .001).ConclusionsAX cannulation for VA-ECMO is a safe and effective alternative to FA cannulation. It can be considered especially for patients with limited groin access, peripheral vascular disease, or for primary graft failure after heart transplant.

Assessment of the efficacy of endovascular treatment in chronic limb-threatening ischemia in diabetic and non-diabetic patients

Aim: Peripheral artery diseases are a very common manifestation of atherosclerosis. We assessed the clinical outcomes of diabetic versus non-diabetic patients with chronic limb-threatening leg ischemia who underwent Peripheral Transluminal Angioplasty (PTA). Methods: The patients (84 diabetic/66 non-diabetic) who underwent percutaneous transluminal angioplasty (PTA) in the lower extremity arterial lesions (stenosis/occlusion) because of chronic limb-threatening leg ischemia (Rutherford class 4 and above) between June 2013 and March 2020 were included in the study. Results: Six-month primary patency rates were 86.5% and 93.3% in the diabetic and non-diabetic group, respectively. The 12-month primary patency rates were 73.0% and 73.3%; and 12-month secondary patency rates were 66.7% and 77.8%. No differences were detected between the groups in terms of patency rates. Major amputation and total amputation rates were higher at statistically significant levels in the diabetic patient group (%16.7% vs. 6.1%; P=0.003) (34.6% vs. 22.8%); P=0.004) Conclusion: When patency and amputation rates are evaluated in diabetic and non-diabetic patient groups with limb-threatening chronic leg ischemia after endovascular treatment, good clinical results were reported in these two groups. Current results suggest that endovascular treatment can be used safely and effectively in both patient groups.

IABP and VA-ECMO is associated with better outcome than VA-ECMO alone in the treatment of cardiogenic shock in STEMI

Abstract Introduction VA-ECMO is an upcoming technique in the treatment of cardiogenic shock in patients with STEMI however it increases afterload. IABP in addition to VA-ECMO has been suggested to reduce afterload and increase survival. Methods A multi-center in-hospital registry was kept on all patients undergoing VA-ECMO or VA-ECMO and additional IABP treatment for cardiogenic shock in STEMI. Patients were analyzed for baseline characteristics, coronary anatomy using the SYNTAX score, predicted survival using the SAVE-score, survival, neurological status and complications. Results Between 2011 and 2018 18 patients with STEMI underwent VA-ECMO +/− IABP treatment for cardiogenic shock. The majority was male (78% (14/18)) with a median age of 59 (47–75) years. All patients were in Killip class IV. VA-ECMO alone was performed in 61% (11/18) and VA-ECMO and IABP was performed in 39% (7/18). A cardiac arrest was observed 91% (10/11) of the patients in the VA-ECMO alone group vs 71% (5/7) in the VA-ECMO+IABP group (p=0.52). The VA-ECMO+IABP group had more complex coronary anatomy, i.e. a higher amount of left main (LM) disease, LM + 3 vessel disease, and three vessel disease when compared to the ECMO alone group (ECMO+IABP 87% vs ECMO alone 18% vs p=0.03). The Syntax score was higher in the ECMO+IABP group (ECMO alone 22±14 vs ECMO+IABP 32±13). The SAVE score did not differ between the groups (ECMO alone −5.9±2.4 vs ECMO+IABP −6.1±2.6 p=0.88) and has a predicted survival of 25–35%. Survival in the VA-ECMO+IABP group was 100% (7/7), survival in the VA-ECMO group was 55% (6/11) (p=0.035). Good neurological outcome was achieved in more patients in the ECMO+IABP group (ECMO alone 45% vs ECMO+IABP 100% p=0.037). There was no difference in leg ischemia between the VA-ECMO alone group vs the ECMO+IABP group (27% (2/11) vs 0% (0/7) p=0.55) or in bleeding complications (18% (2/11) vs 43% (3/7) p=0.28) Conclusion VA-ECMO can improve survival in patients with cardiogenic shock due to STEMI even when in cardiac arrest. VA-ECMO in combination with IABP is associated with better outcome than VA-ECMO alone. Funding Acknowledgement Type of funding source: None

Acute peripheral ischemia in healthy female patient: an indirect and unanticipated diagnosis of spontaneous thrombus in the aortic arch

BackgroundIn this case we discuss the management of a pediculated floating thrombus in the aortic arch which led to peripheral embolization and acute ischemia oft he left leg.Case presentationA healthy 46 year old female patient presented with pain in her left leg and progressive numbness. Computed Tomography Angiography (CTA) showed an acute ischemia of the left leg (Rutherford 2 B) with a 2 cm thrombus distal of the aortic bifurcation. Emergency operation with embolectomy, selective thrombembolectomy and patch plasty on the tibioperoneal trunk and local lysis was performed. As part of a further diagnostic examination a thoracic CT scan has been performed revealing a pediculated-floating 2 cm thrombus in the aortic arch. Four days after the initial operation thrombus excision via a minimally invasive access way has been performed. After initiation of the extracorporeal circulation, selective unilateral antegrade cerebral perfusion has been established in mild (30–32 °C) systemic hypothermia. Patients postoperative course was uneventful. Histological evaluation of the mass demonstrated thrombotic material without evidence of infection or malignacy.ConclusionA pediculated spontaneous thrombus may develop in aortic arch in patients without traditional risk factors or family history of embolic events. Two stage operation was feasible and safe.

DIGITAL ISCHEMIA: IS EPOPROSTENOL EFFECTIVE FOR CONNECTIVE TISSUE DISEASE-ASSOCIATED INTERSTITIAL LUNG DISEASE?

SESSION TITLE: Medical Student/Resident Diffuse Lung Disease SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Epoprostenol (EPO), a prostaglandin analog, has been used for connective tissue disease-associated pulmonary arterial hypertension (PAH) with significant improvement in clinical outcomes, however, the efficacy of prostaglandin analogs in treating digital ulcers associated with dermatomyositis and ILD has conflicting results. We present a patient with ischemic digits and cutaneous ulcerations associated with connective tissue disease and interstitial lung disease (CTD-ILD) that was successfully treated with EPO. CASE PRESENTATION: A 52 years old woman with a history of MDA-5 amyopathic dermatomyositis and CTD-ILD presented with worsening cutaneous skin ulcerations and severe pain in bilateral hands along with findings concerning for digital ischemia [Figure 1-3]. Her previous workup included a chest computed tomography revealing bilateral multiple patchy ground-glass opacities along with interstitial thickening and pulmonary function tests with restrictive lung physiology. During this hospital stay, she continued to develop worsening skin ulcerations (negative arterial dopplers) despite treatment with intravenous immunoglobulins, steroids, mycophenolate, sildenafil, topical nitroglycerin, and botulinum toxin injections. She was therefore, transferred to the intensive care unit for continuous EPO infusion as a last measure to prevent digital necrosis. She tolerated this treatment well with improvement in her pain and prevented digital necrosis. DISCUSSION: In this case, EPO was used to treat severe digital ischemia and pain as a last resort to avoid digital amputation. Prostacyclin analogs used commonly in the USA are EPO and treprostinil. EPO in addition to being a potent vasodilator also has anti-platelet effects, inhibits smooth muscle proliferation, and promotes remodeling response (1). Prostacyclin analogs have been shown to be beneficial for critical leg ischemia, with improvement in digital blood flow and preventing gangrene (1). These medications have an effect on both macro and microcirculation by inducing vasodilation, increasing intracellular cyclic AMP, and by preventing smooth muscle cell proliferation (2). There is limited objective data behind increased blood flow in the digits that correlate with wound healing, however, prostacyclin analogs can help with pain relief due to underlying systemic sclerosis. Currently, very limited data are available for the use of prostacyclin analogs in dermatomyositis associated cutaneous skin ulcerations and digital ischemia. CONCLUSIONS: EPO can potentially be used to prevent the worsening of digital ischemia and pain and associated complications in refractory cases of small vessel vasculitis secondary to dermatomyositis and other connective tissue diseases. Further research and clinical trials are needed to analyze the use of EPO and other prostacyclin analogs for the relief of vascular complications in CTD-ILD. Reference #1: Engel G, Rockson SG. Treprostinil for the treatment of severe digital necrosis in systemic sclerosis. Vasc Med. 2005;10(1):29-32. doi:10.1191/1358863x05vm579cr Reference #2: Rhee RL, Gabler NB, Praestgaard A, Merkel PA, Kawut SM. Adverse Events in Connective Tissue Disease-Associated Pulmonary Arterial Hypertension. Arthritis Rheumatol. 2015;67(9):2457-2465. doi:10.1002/art.39220Kawut, MD, MS Reference #3: Shah AA, Schiopu E, Chatterjee S, et al. The Recurrence of Digital Ulcers in Patients with Systemic Sclerosis after Discontinuation of Oral Treprostinil. J Rheumatol. 2016;43(9):1665-1671. doi:10.3899/jrheum.151437 DISCLOSURES: Advisory Committee Member relationship with GSK Please note: $5001 - $20000 Added 05/22/2020 by Antonio Anzueto, source=Web Response, value=Consulting fee Advisory Committee Member relationship with BI Please note: $1001 - $5000 Added 05/22/2020 by Antonio Anzueto, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Mylan Please note: $5001 - $20000 Added 05/22/2020 by Antonio Anzueto, source=Web Response, value=Consulting fee Advisory Committee Member relationship with AstraZeneca Please note: $1001 - $5000 Added 05/22/2020 by Antonio Anzueto, source=Web Response, value=Consulting fee No relevant relationships by Moeezullah Beg, source=Web Response No relevant relationships by Mahnoor Mir, source=Web Response

Outcomes with Impella in Cardiogenic Shock

Background The Impella (ABIOMED, Danvers, MA) is a temporary left ventricular support device, intended for short-term cardiac support for percutaneous procedures and cardiac shock. The Impella device is available in several sizes capable of producing different flows. It is FDA approved for up to 6 days of support. The device can provide significantly higher blood flow than an intra-aortic balloon pump and can be implanted percutaneously. We sought to describe potential complications and outcomes associated with extended Impella use for cardiogenic shock. Methods We retrospectively evaluated patients who underwent implantation of either the Impella CP (Impella 3.5) or Impella 5.0 from September 1, 2017 to September 1, 2019 at our institution. Hemolysis was defined as plasma free hemoglobin level > 50 mg/dL, a lactate dehydrogenase (LDH) level > 500 units/L, and bilirubin increase > 1 mg/dL. Results 58 patients underwent percutaneous insertion of an Impella device, with the indication of cardiogenic shock in 32 patients (55%). In these 32 patients, only one had an Impella 2.5 device, 21 had an Impella CP (66%), and 10 (31%) had an Impella 5.0. The average age at time of implantation was 55 ± 17 years, and 25 patients were male (78%). Ejection fraction was 17 ± 11.7%. The average duration of Impella support was 5.5 days (1, 16 days). Complications included hematoma at the time of insertion (3 patients), leg ischemia (2 patients), improper positioning (7 patients), acute renal failure (28 patients), and hemolysis (20 patients). Hemolysis developed in 12 patients (57%) with the Impella CP and in 8 patients (80%) with the Impella 5.0, with an average LDH of 1452 units/L. 8 patients were transitioned to veno-arterial (VA) extracorporeal membrane oxygenation (ECMO), with the Impella utilized for left ventricular venting. 9 patients (28%) eventually underwent durable left ventricular assist device (LVAD) implantation on average 7 ± 6.1 days after Impella, and two patients underwent heart transplantation, both 9 days following Impella insertion. 23 patients (72%) did not survive past the initial hospitalization. Conclusion The Impella is a percutaneous temporary left ventricular support device used to provide additional cardiac output in patients with cardiogenic shock. Serious complications can occur with extended support, including hemolysis, acute renal failure, and high mortality. Of our 28 patients who received an Impella, 11 were able to be successfully bridged to either LVAD or heart transplantation with the Impella.

Vascular emergencies-The new COVID-19 crisis?

Vascular emergencies-The new COVID-19 crisis?

A preliminary pilot study investigating the impact of endovascular treatment on leg muscle volume in peripheral artery disease and its relation to baseline glycemic control

Background and aimsPeripheral artery disease (PAD), intermittent claudication, and impaired mobility contribute to the loss of skeletal muscle. This study investigated the impact of endovascular treatment (EVT) in patients suffering from PAD above the knee and its relation to baseline glycemic control. Methods and resultsMid-thigh muscle volume was measured before EVT, 3 months after EVT and 6 months after EVT. Mid-thigh muscle volumes of ipsilateral PAD patients with ischemic and non-ischemic legs were compared. Correlations between total thigh muscle volume and clinical characteristics were analyzed using univariable and multivariable analysis. Overall, thigh muscle volume increased after EVT. The mid-thigh muscle volume was significantly lower in patients with ipsilateral lesions and in those with ischemic lower limbs. The thigh muscle volume of those with ischemic lower limbs increased after EVT. Baseline glycated hemoglobin was the only factor that was negatively correlated with changes in the muscle volume after EVT. Muscle volume significantly increased in normoglycemic HbA1c<6.5% (47 mmol/mol) patients. There was no significant alteration in the muscle volume of hyperglycemic HbA1c ≥ 6.5% patients. ConclusionIschemic muscle atrophy was ameliorated after EVT in normoglycemic patients. There is a need for a large-scale trial to investigate whether EVT can protect or delay skeletal muscle loss.

Role and Prognosis of Extracorporeal Life Support in Patients Who Develop Cardiac Arrest during or after Office-Based Cosmetic Surgery.

BackgroundCardiac arrest during or after office-based cosmetic surgery is rare, and little is known about its prognosis. We assessed the clinical outcomes of patients who developed cardiac arrest during or after cosmetic surgery at office-based clinics.MethodsBetween May 2009 and May 2016, 32 patients who developed cardiac arrest during or after treatment at cosmetic surgery clinics were consecutively enrolled. We compared clinical outcomes, including complications, between survivors (n=19) and non-survivors (n=13) and attempted to determine the prognostic factors of mortality.ResultsAll 32 of the patients were female, with a mean age of 30.40±11.87 years. Of the 32 patients, 13 (41%) died. Extracorporeal life support (ECLS) was applied in a greater percentage of non-survivors than survivors (92.3% vs. 47.4%, respectively; p=0.009). The mean duration of in-hospital cardiopulmonary resuscitation (CPR) was longer for the non-survivors than the survivors (31.55±33 minutes vs. 7.59±9.07 minutes, respectively; p=0.01). The mean Acute Physiology and Chronic Health Evaluation score was also higher among non-survivors than survivors (23.85±6.68 vs. 16.79±7.44, respectively; p=0.01). No predictor of death was identified in the patients for whom ECLS was applied. Of the 19 survivors, 10 (52.6%) had hypoxic brain damage, and 1 (5.3%) had permanent lower leg ischemia. Logistic regression analyses revealed that the estimated glomerular filtration rate was a predictor of mortality.ConclusionPatients who developed cardiac arrest during or after cosmetic surgery at office-based clinics experienced poor prognoses, even though ECLS was applied in most cases. The survivors suffered serious complications. Careful monitoring of subjects and active CPR (when necessary) in cosmetic surgery clinics may be essential.

Lessons Learned from Open Surgical Conversion after Failed Previous EVAR

Delayed open conversion (OpC) after endovascular aortic aneurysm repair (EVAR) is becoming increasingly common worldwide. We reviewed our experience to characterize the perioperative spectrum of OpC repairs. A retrospective analysis of a prospectively maintained institutional database to identify patients who underwent late OpC after failed EVAR was performed. Patient and aneurysm baseline characteristics, mechanism of failure, perioperative details, including type of repair/complications/survival, and late outcomes were examined. From January 2003 to January 2020, 38 male patients (mean age, 75±7years; range, 60-90) required late OpC. Interval time from initial EVAR to OpC was 63.6±33.8months (range, 17-120). Mean diameter of the aneurysms was 82.2±22.1mm before OpC compared with 62.9±13mm before endograft implantation. Mechanisms of failure were type Ia, Ib, II, and III endoleaks in 14 (36.8%), 9 (23.7%), 4 (10.5%), and 1 (2.6%) patient(s), respectively; infection in 3 (7.9%), leg ischemia in 2 (5.3%), and multiple causes in 5 (13.2%) patients. We observed 4 (10.5%) asymptomatic, 16 (42.1%) symptomatic, and 18 (47.3%) ruptured aneurysms. Four patients (10.5%) had stable contained ruptures, whereas the remaining 13 (34.2%) and 1 additional patient (2.6%) with aortoenteric fistula presented with hemorrhagic shock (class ≥II). Total endograft explantation, endograft preservation, or proximal/distal partial graft removal was performed in 16 (42.1%), 10 (26.3%), and 2 (5.2%)/9 (23.7%) of patients, respectively. Technical success was 100%, excluding an early postaortic clamping death. Overall, 30-day mortality was 21.1% (8 of 38) and significantly higher in patients with hemorrhagic shock or hemodynamic instability at presentation (P=0.04 and P=0.009, respectively) and in patients who had endografts with hooks/barbs or experiencing higher postoperative complication rate (P=0.02 and P=0.006, respectively). By definition, procedure success was 81.1%. Mean follow-up was 37.6±39.8months. By the end of the study, we recorded 11 deaths (2 were aneurysm related). Despite high technical success, OpC has a significant mortality in patients presenting with hemorrhagic shock and had active fixation endografts or experiencing high complication rate. Many other confounding factors may play a role.

Double VEGF/HGF Gene Therapy in Critical Limb Ischemia Complicated by Diabetes Mellitus

Critical leg ischemia (CLI) complicated by diabetes mellitus (DM), which is a very common and dangerous disease, represents the ultimate stage of peripheral arterial disease. Patients are treated with antiplatelet drugs, statins and limb revascularization, but a significant number of patients are not candidate for revascularization. Literature shows that in such cases, gene therapy could be a perfect therapeutic option. The aim of our study was to evaluate efficacy of double vascular endothelial growth factor/hepatocyte growth factor (VEGF/HGF) gene therapy in patients with CLI complicated by DM. We observed that 90 days after administration, serum level of VEGF and ankle-brachial index increased significantly (p < 0.001) and rest pain decreased significantly compared with the control group (p < 0.002). Moreover considerable improvement in vascularization was observed in computed tomography angiography (P = 0.04). Based on the results of this study, we suggest that the therapy with pIRES/VEGF165/HGF bicistronic plasmid administration is a safe and effective method of treatment of patients with both CLI and DM.Graphical abstract

Skeletal muscle expression of adipose-specific phospholipase in peripheral artery disease.

Flow-limiting atherosclerotic lesions of arteries supplying the limbs are a cause of symptoms in patients with peripheral artery disease (PAD). Musculoskeletal metabolic factors also contribute to the pathophysiology of claudication, which is manifest as leg discomfort that impairs walking capacity. Accordingly, we conducted a case-control study to determine whether skeletal muscle metabolic gene expression is altered in PAD. Calf skeletal muscle gene expression of patients with PAD and healthy subjects was analyzed using microarrays. The top-ranking gene differentially expressed between PAD and controls (FDR < 0.001) was PLA2G16, which encodes adipose-specific phospholipase A2 (AdPLA) and is implicated in the maintenance of insulin sensitivity and regulation of lipid metabolism. Differential expression was confirmed by qRT-PCR; PLA2G16 was downregulated by 68% in patients with PAD (p < 0.001). Expression of Pla2g16 was then measured in control (db/+) and diabetic (db/db) mice that underwent unilateral femoral artery ligation. There was significantly reduced expression of Pla2g16 in the ischemic leg of both control and diabetic mice (by 51%), with significantly greater magnitude of reduction in the diabetic mice (by 79%). We conclude that AdPLA is downregulated in humans with PAD and in mice with hindlimb ischemia. Reduced AdPLA may contribute to impaired walking capacity in patients with PAD via its effects on skeletal muscle metabolism. Further studies are needed to fully characterize the role of AdPLA in PAD and to investigate its potential as a therapeutic target for alleviating symptoms of claudication.

Outcomes of Catheter-Directed Thrombolysis of Autogenous Vein Bypass Versus Prosthetic Bypass for Acute Leg Ischemia

Outcomes of Catheter-Directed Thrombolysis of Autogenous Vein Bypass Versus Prosthetic Bypass for Acute Leg Ischemia

Regional oxygen saturation change rate for detection of leg ischemia in minimally invasive cardiac surgery.

The criteria for placement of distal perfusion cannulas vary among reports. This cohort study aimed to establish a reproducible method to monitor critical leg ischemia during minimally invasive cardiac surgery. We included 121 patients who underwent minimally invasive cardiac surgery via right thoracotomy with right femoral arterial cannulation from 2015 to 2018. The change rate of regional oxygen saturation (ΔrSO2) was calculated as follows: rSO2 (baseline) - rSO2 (actual number)/rSO2 (baseline). Patients were divided into Group N (ΔrSO2 < 40%): 100/121 (83%) and Group H (ΔrSO2 > 40%, <10 minutes if >40%): 21/121 (17%). A distal perfusion cannula was placed when ΔrSO2 was >40% over 10 minutes. No patients experienced significant leg ischemia. Significantly longer cardiopulmonary bypass and aortic cross-clamp times were observed in Group H than in Group N (cardiopulmonary bypass time, 129 ± 36 minutes (Group N) vs. 151 ± 34 minutes (Group H), p = 0.01). ΔrSO2 correlated positively with plasma creatine phosphokinase elevation (R = 0.40, p < 0.001) on postoperative day 1. Serum lactate on intensive care unit admission showed a significant positive correlation (R = 0.40, p < 0.001) with ΔrSO2. ΔrSO2 measurement by near-infrared spectroscopy can facilitate distal leg perfusion monitoring and assist surgeons in preventing critical leg ischemia during minimally invasive cardiac surgery.

Blood lactate predicts survival after percutaneous implantation of extracorporeal life support for refractory cardiac arrest or cardiogenic shock complicating acute coronary syndrome: insights from the CareGem registry

Refractory cardiogenic shock (RCS) or refractory cardiac arrest (RCA) complicating acute coronary syndrome (ACS) is associated with extremely high mortality rate. Veno-arterial extracorporeal life support (VA-ECLS) represents a valuable therapeutic option to stabilize patients’ condition before or at the time of emergency revascularization. We analyzed 29 consecutive patients with RCS or RCA complicating ACS, and implanted with VA-ECLS in two centers who have adopted a similar, structured approach to ECLS implantation. Data were collected from January 2010 to December 2015 and ECLS had to be percutaneously implanted either before (within 48 h) or at the time of attempted percutaneous coronary revascularization (PCI). We investigated in-hospital outcome and factors associated with survival. Twenty-one (72%) were implanted for RCA, whereas 8 (28%) were implanted on ECLS for RCS. All RCA were witnessed and no-flow time was shorter than 5 min in all cases but one. All patients underwent attempted emergency PCI, using radial access in ten cases (34.5%), whereas in three patients a subsequent CABG was performed. Overall, ten patients (34.5%) survived, nine of them with a good neurological outcome. Life threatening complications, including stroke (4 pts), leg ischemia (4 pts), intestinal ischemia (5 pts), and deep vein thrombosis 2 pts), occurred frequently, but were not associated with in-hospital death. Main cause of death was multi-organ failure. PCI variables did not predict survival. Survivors were younger, with shorter low-flow time, and with ECLS mainly implanted for RCS. At multivariate analysis, levels of lactate at ECLS implantation (OR 4.32, 95%CI 1.01–18.51, p = 0.049) emerged as the only variable that independently predicted survival. In patients with RCA or RCS complicating ACS who are percutaneously implanted with ECLS before or at the time of coronary revascularization, in hospital survival rate is higher than 30%. Level of lactate at ECLS implantation appears to be the most important factor to predict survival.