Lower Limb Claudication Research Articles

TAVI-related vascular access complications: are Viabahn stents a good option?

Abstract Background Vascular access complications (VACs) remain one of the biggest challenges when performing transcatheter aortic valve implantation (TAVI). Historically, concerns regarding stent placement in flexing points have been a deterrent to the percutaneous treatment of VACs, due to the potential development of claudication over time. The Viabahn stent, being a covered stent that offers flexibility and conformability, may be well-suited for deployment in these anatomies. Purpose This study aimed to evaluate the safety and efficacy of the iliofemoral Viabahn stenting for treating TAVI-related VACs. Methods Retrospective analysis of patients submitted to Viabahn stenting in the iliofemoral sector for TAVI-related VACs in a single tertiary centre between January 2017 and October 2023. Baseline characteristics, procedure data and complications were noted according to the Valve Academic Research Consortium-2. Results A total of 722 patients were submitted to transfemoral TAVI during the study period. Of these, 25 (3.6%) underwent Viabahn stenting to treat TAVI-related VACs and were included in this study. Patient mean age was 82.1±6.13 years, 61.2% were male. At the baseline, patients had a mean Euroscore II of 2.73±1.91. A unilateral access approach was used in 40% of cases. The median size of the main access sheath was 14 Fr [IQ 14-16], and the closure devices deployed were Manta® in 72%, and Perclose® in 28%. The Viabahn stent treated different types of VACS, including vessel rupture in 56%, acute dissection in 28% (12% with no antegrade flow), and failed sealing in 16%. The complicated artery was the common femoral in 82%, and the external iliac in 18%. Percutaneous treatment with Viabahn stenting was successful in 92% of cases. In two cases (8%), one of acute occlusion and one of vessel rupture, vascular surgery was required. During the hospital stay, there were no further vascular or hemorrhagic complications. After a mean follow-up of 15 months, 20% of patients were evaluated by Doppler which showed no signs of restenosis or stent complications. Only one patient experienced lower limb claudication at 1 year due to stent restenosis detected in the CT scan, which was managed with medical therapy. There were no other adverse vascular events during follow-up. Conclusion Our study suggests that Viabahn stenting emerges as a valuable therapeutic option, ensuring long-term safety and efficacy, in the complex realm of TAVI-related vascular complications.

Thoracic aortic coarctation with asbestos-induced pleural fibrosis presenting as lower limb claudication

Asbestos exposure is a well-documented cause of pulmonary diseases. However, its systemic effects, particularly on the cardiovascular system, are less understood. We expose a case that highlights an unusual cardiovascular manifestation in a patient with a history of pleural asbestosis compressing the aorta and clinically manifested as lower limb claudication. A 65-year-old individual presented with bilateral short-distance lower extremity claudication. The patient’s clinical presentation prompted advanced imaging studies, including CT angiography, to assess the extent of vascular involvement. The imaging confirmed the presence of substantial calcification and narrowing of the thoracic aorta. The patient had a documented history of pleural asbestosis. This case underscores the potential for asbestos-related diseases to extend beyond pulmonary manifestations, affecting cardiovascular health. The observed aortic calcification and coarctation represent an atypical progression of asbestosis related pathology.

Extracorporeal Shockwave for Intermittent Claudication and Quality of Life

Intermittent lower limb claudication limits function and quality of life. Supervised exercise programs are not readily available, and a noninvasive alternative is needed. To assess extracorporeal corporeal shockwave therapy in improving quality of life in patients with claudication. In this double-blind, placebo-controlled randomized clinical trial, patients in the outpatient setting at a single tertiary center for vascular surgery were randomized in a 1:1 ratio to extracorporeal shockwave therapy or placebo therapy with no shockwaves delivered. Recruitment was between June 2015 and January 2020, with 12-week follow-up ending in March 2020. A convenience sample of patients with claudication and conservative treatment requirements who refused or were unable to participate in supervised exercise were eligible. Patients receiving anticoagulation therapy or with an active cancer were excluded. Of 522 patients screened, 389 were eligible, 138 were enrolled, and 110 completed follow-up and were included in the primary analysis. Statistical analysis was completed by May 2021. In the intervention group, patients received 100 impulses of 0.1mJ/mm/cm2 in an area of the gastrocnemius muscle 3 times weekly for 3 weeks. The steps for treatment were replicated for the control group without delivering the treatment. The primary outcome was the Physical Functioning domain of the 36-item Short-Form Quality of Life Questionnaire at 12-week follow-up. Secondary outcomes included walking distances, ankle brachial pressure index, and other quality-of-life measures. Of 138 patients recruited and randomized, 92 (67%) were male, and the mean (SD) age of the study population was 67 (9.6) years. The intervention group had a significantly higher physical function score at 12 weeks (estimated median difference 3.8; 95% CI, 0.0-7.7; P = .03). However, this significance did not remain when adjusting for covariates. At 12 weeks, the intervention group had significantly longer pain-free and maximum walking distances (pain-free estimated median difference, 34.1, 95% CI, 11.4-56.8; P = .004; maximum estimated median difference, 51.4; 95% CI, 10.7-86.5; P = .01). To our knowledge, this is the first double-blind, placebo-controlled, randomized clinical trial to consider extracorporeal shockwave therapy for the management of intermittent claudication. It demonstrated efficacy for walking distances, may have a positive effect on quality of life, and may provide a safe, noninvasive alternative therapy for patients with intermittent claudication. ClinicalTrials.gov Identifier: NCT02652078.

Supervised Exercise Training May Improve Postural Control in Patients with Symptomatic Lower Extremity Peripheral Artery Disease.

Patients with symptomatic peripheral artery disease (PAD) have been shown to present balance disorders and a history of falling, which are associated with functional and daily life impairments. Although postural control improvement is an important outcome, the benefits of supervised exercise training (SET) on postural control have been seldom investigated in these patients. This article investigates the effects of SET on traditional measures of postural control and on stabilogram-diffusion analysis (SDA) parameters in patients with symptomatic PAD. Patients with symptomatic chronic lower limb claudication were investigated. All subjects who completed the 3-month multimodal SET program and postural control assessment before and after SET were included. Center of pressure trajectory analysis and SDA parameters were investigated using a posturographic platform. Patients were instructed to stand on the platform and maintain balance to their best ability. Treadmill pain-free (PFWD) and maximal (MWD) walking distances were also assessed prior and following SET. Forty-four patients with PAD (65.2 ± 9.8 years, 34% women) were investigated. All postural control parameters were unchanged following SET, except the length of center of pressure displacement as a function of the surface of center of pressure trajectory (LFS), which was significantly increased (before SET: 1.4 ± 0.4; after SET: 1.5 ± 0.5; p = 0.042). PFWD (before SET: 103.5 ± 77.9 m; after SET: 176.8 ± 130.6 m; p ≤ 0.001) and MWD (before SET: 383.6 ± 272.0 m; after SET: 686.4 ± 509.0 m; p ≤ 0.001) significantly improved following SET. The increased LFS suggests a better postural control accuracy following SET in patients with symptomatic PAD.

The Role of Ankle Brachial Index in Patient with Peripheral Arterial Disease; Diagnostic and Prognostic Tool

Objectives: Peripheral arterial disease is an independent risk factor for developing major cardiovascular events, and even death; this makes its diagnosis important in early detection and prevention of these events. Ankle brachial index is a non-invasive, simple, bedside screening, diagnostic and even prognostic tool, patients with ABI less than 0.9 were found to have PAD, and at risk of cardiovascular events. Methods: A descriptive cross-sectional study of 338 patients was conducted during the period October 2021 to December 2022. They were referred to vascular and endovascular surgery unit at Ghazi Al-Hariri multispecialty teaching hospital/ Medical city teaching, they were presented with intermittent claudication and other PAD symptoms. Peripheral endovascular angioplasty was done; all were subjected to Ankle brachial index measurement. Results: The study involves 338 patients, among them males were 242 (72%), females were 96 (28%). Age ranged from 25-92 years old, with an age average of 61 years. A total of 203 (60%) were presented with classical lower limb claudication, 100 (30%) patients with atypical symptoms and only 35 (10%) patients with critical limb ischemia. A total of 216 (64%) patients with ABI between 0.4-0.9; 100 (29%) patients with ABI greater than 0.9; 19 (6%) patients with ABI less than 0.4, and only 3(1%) patients with ABI more than 1.4. Conclusion: Ankle brachial index is a useful, cost effective, simple non-invasive diagnostic tool in patients with peripheral arterial disease.

Calcification of Joints and Arteries (CALJA) Is a Rare Cause of Arthritis and Lower Limb Ischemia: Case Report and Literature Review

Calcification of Joints and Arteries (CALJA) is a rare disease that leads to chronic arthritis and lower limb claudication due to hydroxyapatite crystal deposition. The disease is caused by mutations in the 5-nucleotidase (NT5E) gene, which is responsible for pyrophosphate metabolism. Only 23 cases have been described so far. In this case report, we describe a new case of CALJA and provide a literature review. A 65-year-old woman was referred to the Rheumatology Unit with the diagnosis of seronegative oligo-arthritis. She complained of lower limb claudication, which was becoming progressively worse. Doppler ultrasound revealed bilateral obliteration of the popliteal and femoral arteries, and X-rays of the knees, hands, and feet showed extensive periarticular calcific deposits. The results of the NT5E gene analysis were positive for an inactivating variant, leading to the diagnosis of CALJA. The clinical features of CALJA are caused by hydroxyapatite crystal deposition at the periarticular and vascular levels due to abnormalities of pyrophosphate metabolism. Currently, no specific treatment is available, although a trial on the use of etidronate is ongoing. Patients with CALJA are often treated with immunosuppressant agents in the suspect of inflammatory rheumatologic diseases. Our case is the first in which clinical symptoms and a steady increase of inflammatory markers improved only after colchicine therapy initiation. It is crucial for the rheumatologist to recognize the features CALJA and keep it in mind in the differential diagnosis of patients with lower limb arterial insufficiency and arthritis or early osteoarthritis with joint calcification.

Psychiatric sequelae of thromboangiitis obliterans: a case report and review of the literature

BackgroundPeripheral manifestations secondary to progressive vascular occlusions are characteristic of the rare condition termed thromboangiitis obliternas (TAO) or Buerger’s disease. The central manifestations of this disease are however poorly characterized, particularly those of psychiatric nature, and their prevalence is largely unknown. Speculations have been made around the polymorphic nature and triggers of observed psychopathology in TAO; much however remains to be unraveled in this area.Case presentationWe present the case of a 33-year-old Caucasian male who developed first episode of psychosis at the age of 29 years. There was no history of previous mental illness either in the patient, or in any of his family members. He had been a long- term heavy smoker and was experiencing progressive lower limb claudication since the age of 22 years; however, all inflammatory, autoimmune and atherosclerotic markers were negative. His psychosis was characterized by retention of a warm affect, and despite some amelioration, was generally resistant to a fair trial of several anti-psychotic medications including Clozapine.ConclusionThe pathophysiology of psychosis secondary to Buerger’s is not yet well characterized which adds to the complexity of managing these cases. Recognizing that cerebral manifestations of this disease may evolve several years after the onset of peripheral thromboangiitic features is important for following the natural history and considering measures that may reduce the burden of illness.

JS-AHA: AHA SESSION CLINICAL CASE; CLINICAL-PATHOLOGICAL CONFERENCE (CPC) IN COOPERATION WITH HYPERTENSION, AN AMERICAN HEART ASSOCIATION JOURNAL

A 35-year-old woman, with a known history of right renal artery FMD, presented at the Hypertension Outpatient Clinic for evaluation of resistant hypertension. The patient was an active smoker and had a single kidney after left nephrectomy for kidney malformation during childhood. The diagnosis of FMD had been made on the occasion of a previous pregnancy at 23 years, complicated by preeclampsia and an angioplasty had been performed. Work-up disclosed a recurrence of right renal artery stenosis, and a new renal angioplasty was performed. Blood pressure normalized after the procedure. At 36 years, the patient had another pregnancy, also complicated by preeclampsia and preterm delivery. An Echo-Doppler performed during pregnancy and an Angio-CT after delivery, allowed ruling out recurrence of renal artery stenosis. At 43 years, she was admitted to the emergency room for thoracic pain. The coronarography was in favour of a coronary spasm. There was no coronary stenosis or image suggestive of a Spontaneous Coronary Artery Dissection. At 54 years, the patient was again admitted in emergency for malignant hypertension associated with severe acute renal failure. She also reported a history of lower limbs claudication since several months. An abdominal CT disclosed dissection complicated by occlusion of the right renal artery, dissection of both iliac arteries as well as a severe stenosis of the infra-renal aorta. An angioplasty with insertion of stents in the right renal artery and the aorta was performed. After the procedure, a partial normalization of renal function was observed, and blood pressure control was achieved on 3 medications. During the recovery, the patient presented a skin rash associated with a general feeling of discomfort, with spontaneous resolution after a few days. One year later, following a control Angio-CT of the abdomen, an anaphylaxis episode occurred, requiring Adrenaline administration. Iodine contrast allergy was suspected, but milder hypersensitivity symptoms occurred in the following months, without exposition to a clear trigger. An allergology work-up was performed with final diagnosis of secondary Mast Cell Activation Syndrome. B-Blockers and ACE-inhibitors were contra-indicated and cautious premedication before further exposure to iodine contrast was recommended.

Collateral circulation − “Hand of God:” Salvaging the transplant kidney!

The physiological adaptation capability of any living being is necessary for survival. Vascular collaterals are proven to be maintaining organ perfusion in various situations such as ischemic heart disease, cerebrovascular disease, and peripheral vascular diseases. We are presenting here a postrenal transplant case with renal graft perfused by collaterals because of the complete occlusion of right common iliac artery. This was diagnosed while the patient presenting with right lower limb claudication pain. He required femoro-femoral graft to perfuse the right lower limb. The importance of pretransplant iliac vessels imaging and Doppler studies is emphasized.

Red blood cell distribution width as a predictor of cardiovascular outcomes in extensive aortoiliac disease.

Aortoiliac peripheral artery disease may lead to disabling lower limb claudication or to lower limb chronic threatening ischemia, which is associated with increased short and long-term morbi-mortality. The red blood cell distribution width-coefficient of variation (RDW-CV) has been able to predict outcomes in other atherosclerotic diseases, such as myocardial infarction and stroke. The main objective of this study was to assess the predictive ability of perioperative RDW-CV in accurately predicting short and long-term major adverse cardiovascular events (MACE) and all-cause mortality in patients submitted to aortoiliac revascularization due to extensive aortoiliac atherosclerotic disease. From 2013 to 2020, patients who underwent aortoiliac revascularization due to severe aortoiliac disease were included in a prospective cohort. Blood samples were taken preoperatively and the patient's demographics, comorbidities, and postoperative outcomes were assessed. A multivariate Cox regression model was used to adjust for confounding and assess the independent effect of these prognostic factors on the outcomes. The study group included 107 patients. Median follow-up was 57 (95% CI: 34.4-69.6) months. Preoperative RDW-CV was increased in thirty-eight patients (35.5%). Increased RDW-CV was associated with congestive heart failure - adjusted odds ratio of 5.043 (95% CI: 1.436-17.717, P=0.012). It could predict long-term occurrence of MACE (adjusted hazard ratio [aHR] 1.065, 95% CI: 1.014-1.118, P=0.011), all-cause mortality (aHR=1.069, 95% CI: 1.014-1.126, P=0.013), acute heart failure (AHF) (aHR=1.569, 95% CI: 1.179-2.088, P=0.002), and stroke (aHR=1.343, 95% CI: 1.044-1.727, P=0.022). RDW is a widely available and low-cost marker that was able to independently predict long-term AHF, stroke, MACE, and all-cause mortality in patients with extensive aortoiliac disease submitted to revascularization. This biomarker could help assess which patients would likely benefit from stricter follow-up in the long-term.

Takayasu Arteritis and Lower Limbs Claudication: A Rare Presentation

Takayasu´s arteritis is a rare inflammatory disease of large- and medium-sized arteries which predominantly affects women of middle-aged. We report an unusual case of Takayasu arteritis in a 54-year-old woman presenting with progressive lower limbs intermittent claudication. Aneurysmal and stenotic vascular lesions involving both common iliac arteries were identified which also represents a very uncommon anatomical distribution in this pathology. In addition, we share our experience with endovascular intervention for stenotic lesions.

Popliteal Entrapment Syndrome: Diagnostic, Surgical Management, and Short-Term Results of a Ten-Year Experience

Popliteal artery entrapment syndrome (PAES) is a rare cause of lower limb claudication in young sportsperson without cardiovascular risk factor. We reported our diagnostic approach, surgical management, and short-term outcomes of this syndrome, over a 10-year period. Sportsperson with intermittent claudication systematically received color duplex ultrasonography with dynamic maneuvers in the sport medicine department. In case of PAES suspicion, diagnosis was confirmed by dynamic computed tomography or dynamic magnetic resonance angiography. Each patient was then evaluated by a vascular surgeon and surgery was performed. We retrospectively screened patients who underwent PAES surgery between 2010 and 2020 in the Department of Surgery in Angers University Hospital. Between January 2010 and December 2020, 38 patients with 67 symptomatic legs underwent surgery for PAES. Twenty three (60.5%) were men. The mean age at the time of surgery was 24.7 +/- 9years. Clinical presentation was bilateral in 30 patients (81.1%). Duplex ultrasound demonstrated severe stenosis or occlusion in 45 legs (77%). When performed, CT-scan demonstrated popliteal artery compression in all cases (100%). As per Whelan and Rich classification, 36 patients (94.7%) had type 6 PAES. There was no mortality or severe complication after surgery. Morbidity included 4 postoperative hematoma (6%) and 8 prolonged healing (13%). The mean time of follow-up was 2.3months +/- 1.2months. After surgery, D-scan showed no signs of remaining popliteal artery compression in 92.5% of the case. Twelve patients (33.3%) were able to resume sport, 18 (50%) partially, and 6 (16.6%) did not resume sport yet. We report a cohort of 38 patients who underwent surgery for PAES. Among them, 36 (94.7%) were functional PAES. Morbidity included 13% of prolonged healing. Two months follow-up demonstrated good results at dynamic D-scan without signs of remaining popliteal artery compression in 92.5% of the cases. These short-term results showed that one-third of patients were able to resume sport activity at an initial level.

A Prospective Study on Type-2 Diabetic Complications and Efficacy of Integrated Yoga: A Pan India 2017.

Background:Type 2 diabetes (T2DM) contributes to high mortality and morbidity because of its major complications related to kidney, heart, brain, and eyes. It also poses a high risk for mortality because of COVID-19. Studies suggest the possible implications of Yoga in delaying or attenuating such complications.Methodology:This was a pan-India multi centered cluster-randomized (4 level) two-armed trial in the rural and urban population of all populous states of India. Data were obtained using mobile app in all adults in the household of the selected clusters.Results:We report the diabetes related complications in 16623 adults (48% males, 52% females) from 65 districts (1 in 10 districts, 2011 census) of 29 (out of 35) states and Union Territories of India; mean age was 48.2 ± 12.46 years. Out of this 40% lived in rural and 62% in urban locations. In high risk diabetes individuals (scored ≥ 60 points on Indian diabetes risk score key), 18.0% had self-reported history of (peripheral neuropathy, 6.1% had h/o major strokes, 5.5% had minor strokes (transient ischemic episodes), 18.1% had lower limb claudication, 20.5% leg ulcers, 4.4% had h/o cardiac surgery, 4.8% angioplasty, and 15.1% had diabetes retinopathy. Complications were higher in rural than in urban areas, higher in people with extended duration of diabetes. Integrated yoga module for three months (one hour daily) showed significantly better reduction in symptoms related to complications as compared to control group (P < .001)Conclusion:The alarming high prevalence of complications in diabetes population calls for urgent action, where yoga may show the benefits in reduction of symptoms of complications.

Winslow Pathway Collaterals: An Unusual Arterial Network in Takayasu Arteritis

Takayasu arteritis which is reported more commonly from Asia and in females can present as middle aortic syndrome with lower limb claudication. We present a case of a young male with Takayasu arteritis with middle aortic syndrome and Winslow pathway collaterals with lower limb ischaemia, hypertension, coronary occlusion and stroke. The extensive collateral formation was visible as a clinical finding over the abdominal wall. The identification of these collateral pathways is essential in understanding the extent of haemodynamically significant disease and it alerts to the possibility of surgical injury during procedures like laparotomy or harvesting of internal thoracic artery for coronary artery bypass graft.

Refractory heart failure and intermittent claudication secondary to supra-renal coral reef aorta

Coral reef aorta (CRA), a rare disease, is characterized by severe calcification of the juxta-renal and suprarenal aorta that grows into the lumen and leads to severe stenosis. A 70-year-old woman with refractory hypertension and lower limb claudication presented with hypertension and congestive heart failure. Treatment with vasodilators and diuresis led to oliguria and exacerbated kidney function, while her congestion remained. Abdominal computerized tomography showed a bulky, irregular localized supra-renal aortic calcification with stenosis. A peripheral artery ultrasound and angiography showed no occlusive lesions in the distal run-off vessels. Based on her medical history and the unique aspects of the localized calcified lesion, CRA was diagnosed. We suspected that the congestive heart failure, refractory hypertension, and renal failure resulted from the supra-renal aortic stenosis. Because she developed oliguria with diuretics and vasodilators, we performed an open graft replacement with a thoracoabdominal approach. The reddish-brown calcified mass came off easily and was very fragile. The postoperative course was uneventful, and her heart and renal failure were completely resolved. This is the first report showing the fragility of CRA. Considering its fragility, catheter treatment may need to be avoided to prevent distal embolism.<Learning objective: When we encounter a calcified lesion localized at the level of the juxta and supra-renal aorta with extensive growth into the lumen, coral reef aorta (CRA) should be suspected. Considering that CRA lesion can be very fragile in contrast to the usual atherosclerotic lesion, as shown in our case, CRA might possibly increase the risk of distal embolization. Therefore, open graft replacement could be safer than endovascular stent-graft placement.>

Outcomes of Surgical and Endovascular Treatment for Arterial Lesions in Intravenous Drug Abusers

The objective of this study is to report an 18-year single-center experience in the surgical and endovascular treatment of arterial complications due to self-injection in drug abuser patients. This retrospective single-center study was conducted analyzing a prospectively collected database including all endovascular or surgical procedures performed from January 2007 to December 2019 for any arterial complication due to self-injection in drug abuser patient. Collected data were patient demographic and comorbidity, site and type of arterial lesion (pseudoaneurysm [PA], arteriovenous fistula [AVF]), signs of systemic or local infection, and procedural data (endovascular/surgical treatment). End points were rate of postoperative complications, reintervention rate, limb salvage, and patients' early and long-term survival. In 11 patients (median age 36years, range 27-47; male 73%), 13 arterial lesions were treated: 10 (77%) PA, 2 (15%) PA associated with AVF, and 1 (8%) isolated AVF. Arterial lesion involved common femoral artery in 5 (38%), superficial femoral artery in 4 (31%), profunda femoral artery in 1 (8%), brachial artery in 2 (15%), and subclavian artery in 1 (8%). Signs of infections were present in 9 of the 13 cases (69%). The treatment was surgical in 11 (85%) cases: 7 interposition graft (6 great saphenous vein, 1 arterial cryopreserved homograft), 2 direct reconstruction, 1 patch plasty with pericardium bovine patch, and 1 arterial ligation. Endovascular treatment was performed in 2 cases: 1 noninfected PA of the superficial femoral artery, and 1 55-mm PA of the postvertebral segment of the right subclavian artery with clinical sign of hemodynamic instability. At 1month, postoperative complication rate was 8% (one lower limb claudication after superficial femoral artery ligation). Reintervention rate was 8% (interposition graft rupture for repeated self-injections). Limb salvage and patient survival were both 100%. Median follow-up was 5years (range 1month to 11.3years); surgical group: median 8.2years (range 2months to 11.3years); endovascular group: median 3.5months (range 1-6). During follow-up, neither complications nor reinterventions occurred, and limb salvage was 100% for both groups. At 2, 4, and 6years, overall estimated patient survival was 91%, 81%, and 81%, respectively, with no procedure-related death. After surgical or endovascular management of arterial lesions due to self-injection in drug abuser patients, complications occur mainly in the postoperative period. During follow-up, the surgical procedures have low rate of complications, reinterventions, and procedure-related mortality, whereas for the endovascular treatment the mid-term outcomes remain unknown.

Endarterectomy for Isolated Atherosclerotic Lesions of the Popliteal Artery

In the endovascular era, angioplasty has grown a large place in the treatment of peripheral artery disease. Few studies have been focused in short atherosclerotic lesions of the popliteal artery itself, which remain for many surgeons a critical zone for the technical approach decision. We herein describe simple techniques of popliteal endarterectomy for the treatment of short popliteal occlusive disease. Between January 2011 and June 2019, patients with isolated popliteal artery atherosclerotic lesions were included in this retrospective study. Indication for intervention was either disabling lower limb claudication or critical limb ischemia. We performed either endarterectomy by eversion of the popliteal artery or a simple endarterectomy with a patch angioplasty. We then studied the procedural data, the thirty-day outcomes, and the mid-term follow-up. A total of 17 patients were included in the study, and 18 limbs were revascularized with the endarterectomy technique. Total duration of the procedure was 100±46min. Overall technical success was 100%. Median hospital stay was 4days. Complete clinical success, that is, freedom from claudication or rest pain, was achieved in all cases. No early additional procedure was needed. After a mean follow-up of 34±32months with no patient lost to follow-up, all patients were alive, and a 100% primary patency and limb salvage was observed. At 3years' follow-up, endarterectomy of the popliteal artery appears to be a valid option for isolated and short atherosclerotic lesions.

Surgical Fenestration of the Abdominal Aorta in Patients with Acute and Chronic Aortic Dissection

Introduction - Surgical aortic fenestration for acute and chronic aortic dissection has been used at our institution since 1986. The aim of the study is to define the indications for its use and to evaluate its success at relieving organ or limb malperfusion. Methods - The records of all patients (n=57) who underwent surgical fenestration of abdominal aorta at our department during the past decade (from 2007 to 2017) were identified. Emergency aortic fenestration for treatment of acute aortic dissection underwent 2 patients with type B dissection. Clinical presentation was malperfusion syndrome: 1 patient had bilateral lower limb and renal ischemia and 1 patient had acute renal and mesenteric ischemia. In both cases malperfusion syndrome occurred despite prior proximal descending throracic aortic replacement. The mean interval between malperfusion onset and fenestration was 7 hours (range, 6 - 8 hours). 55 patients underwent elective aortic fenestration for treatment of chronic aortic dissection. 2 patient had type A dissection, and 53 patients had type B dissection. The primary clinical presentation was chronic malperfusion syndrome in all 55 patients and infrarenal aortic aneurysmal disease in 5 patients. Among them 9 patients had lower limb claudication, 41 patients had renal ischemia, and 17 patients had severe refractory renovascular hypertension caused by the compressed true lumen. 7 patients had symptoms related to chronic mesenteric ischemia. 2 patients had prior ascending aortic Bentall procedure and 5 patients - prior proximal descending thoracic aortic replacement. The main condition and indication for surgical aortic fenestration was the absence of aneurysmal enlargement of the abdominal aorta at the para and suprarenal level (aortic diameter less then 5 cm). Abdominal aortic fenestration was performed through longitudinal aortotomy at the para- and suprarenal level by resection of the septum between the false and true lumen. The aortotomy then was sutured and reinforced with strips of Teflon, which resulted in a slightly redused aortic diameter. Concomitant graft replacement for the infrarenal abdominal aorta was done in 14 patients. Results - The malperfusion syndrome was relieved for 55 patients with organ or limb ischemia. Early operative survival from fenestration was 96.5 % (55 /57). In the acute dissection group the operative mortality was 50 % (1/2) and cause of death - anuria and bowel ischemia. In one patient, acute renal and lower limb malperfusion syndrome was successfully relieved. In the chronic dissection group, operative mortality was 1.8 % (1/55), with the cause of death being multi-systemic organ failure. The 54 patients with evidence of chronic malperfusion syndrome had complete relief. None of the patients were seen with complications that called for reoperation. The mean follow-up for 54 survivors was 3 years (range, 3 months to 5 years). All patients remained free from symptomatic recurrence of malperfusion syndrome and had postoperative imaging studies done. Among all patients there was no evidence of aneurysmal formation at the site of aortic fenestration. Conclusion - Surgical fenestration of the abdominal aorta is a safe and effective method for the treatment of ischemic complications associated with the aortic dissection and malperfusion.

Do Not Forget to Pull the Graft!

A 71 year old woman presented with a two month history of left lower limb claudication. Her history included an above knee femoropopliteal bypass using a 7 mm heparin bonded expanded polytetrafluoroethylene graft (Propaten, WL Gore & Associates, Flagstaff, USA) six months previously for critical limb ischaemia (rest pain). Computed tomography angiography revealed a thrombosed graft, severely kinked where it lay beneath sartorius (A and B). Lack of appropriate intra-operative graft pulling and straightening probably caused the problem. This case illustrates the importance of intraoperative quality control after bypass surgery to prevent kinks or other problems that might hinder flow and predispose to occlusion.Image 1

18. An unusual PET project: large vessel vasculitis presenting as lower limb claudication in the absence of aortitis

IntroductionRheumatologists are increasingly aware of extracranial giant cell arteritis (GCA), namely large vessel vasculitis (LVV) involving the aorta and its branches. It is uncommon for patients to present with claudication as their initial complaint. We present an unusual case of femoral arteritis presenting with lower limb claudication. PET-CT demonstrated increased uptake bilaterally in the femoral arteries with typical hypoechoic haloes on Doppler ultrasound. There was no evidence of aortitis. We also illustrate the diagnostic challenge differentiating between vasculitis and atherosclerosis on PET-CT and how steroid-therapy reduces the sensitivity PET imaging.Case descriptionA 57-year-old lady with known hypertension presented to her local hospital with a 3-year history of worsening claudication in her lower limbs. Her exercise tolerance was limited to 50 metres over the past 2 months and she had rest pain. Other symptoms included widespread musculoskeletal pain, chest pain, headaches and jaw pain on mastication. Lower limb Doppler ultrasound demonstrated significant stenosis of the distal femoral arteries bilaterally with hypoechoic haloes typical for vasculitis. Immunology tests were all negative but inflammatory markers were raised (ESR 43 mm/h, CRP 14 mg/L). In view of the Doppler findings and GCA symptoms she was started on prednisolone 60mg. The prednisolone was held 2 days before a PET-CT which demonstrated mild uptake in both femoral arteries with no evidence of aortitis. Her CT angiogram showed significant diffuse atheromatous disease in the superficial femoral and popliteal arteries bilaterally. In view of this, the PET-CT uptake was thought to be in keeping with atherosclerosis rather than vasculitis. Her prednisolone was therefore stopped and she was transferred to a tertiary vascular centre for further management. The vascular team at our hospital were still concerned about the possibility of vasculitis and a second rheumatology opinion was sought. Her inflammatory markers continued to rise (ESR 76 mm/h, CRP 29 mg/L). It was felt that the PET-CT results may have been affected by high-dose prednisolone which was temporarily held. The PET-CT was therefore repeated having been off steroids for 4 weeks. This demonstrated increased uptake in the superficial femoral and profunda arteries when compared to her previous scan. All her images were reviewed and the diagnosis was felt to be in keeping with LVV. Furthermore, she had a good clinical response to 40mg prednisolone and methotrexate was subsequently added.DiscussionClassical GCA typically presents with cranial symptoms. Extracranial symptoms such claudication can occur although only 4% of patients fall into this category. In our patient, femoral arteritis presented with lower limb claudication. Peripheral limb ischaemia and/or aorta involvement is associated with a slightly younger demographic of LVV (<60 years). Initially, there was diagnostic uncertainty given her raised inflammatory markers and hypoechoic femoral artery haloes on Doppler ultrasound, yet diffuse atherosclerosis on the CT angiogram. Hypoechoic haloes and multiple short segment occlusions are more typically seen in vasculitis rather than atherosclerotic disease. Accelerated atherosclerosis is common in primary vasculitides. Despite establishing the diagnosis of LVV by ultrasound in this case, the sensitivity for this in the common femoral artery is < 17%, and PET-CT is preferred. EULAR recommendations for LVV diagnosis include ultrasound and PET-CT. PET-CT was performed twice in this patient because the initial scan was performed following temporary cessation of high-dose steroids, which can decrease the sensitivity of PET-CT. The first PET-CT showed only mild uptake in the femoral arteries which could be consistent with atherosclerosis. Interestingly, PET-CT has been used to identify plaques vulnerable to rupture bed on FDG-avidity. Recent studies have utilised PET-CT to quantify the burden of atherosclerotic disease to help risk stratify patients accurately. This potential diagnostic ambiguity between vasculitis and atherosclerosis on PET-CT reinforces the importance of remaining off steroids around the time of PET imaging where possible.Key learning pointsThis case sheds light on LVV through several interesting perspectives. Firstly, it is unusual for LVV to present with claudication in the lower limbs in the absence of aortitis, demonstrating the variety of ways in which the same pathophysiological mechanism can present clinically. We also highlight the initial diagnostic challenge, as mild uptake in the femoral arteries on PET-CT can be consistent with atherosclerosis. However, with typical findings of hypoechoic haloes on Doppler ultrasound and raised inflammatory markers, clinically this was in keeping with LVV. Interestingly, a repeat PET-CT off steroids demonstrated increased FDG-avidity in the affected areas. This is important as even holding steroids for 2 days before a PET-CT affected the results of the study. This case adds to the growing number of atypical extracranial presentations of LVV and provides useful insight for future possible cases.Conflict of interestThe authors declare no conflicts of interest.