Lower Limb Ischemia Research Articles

Effectiveness of spinal cord stimulation in diabetic patients with chronic limb-threatening ischemia: small cohort study

BackgroundChronic limb-threatening ischemia (CLTI) is the most severe form of peripheral artery disease (PAD). Patients with diabetes mellitus (DM) have a faster progression of PAD and a fourfold increased risk of CLTI compared to patients without DM. Epidural spinal cord stimulation (SCS) has been used as a method to improve microcirculation, relieve ischemic pain and reduce the number of amputations in patients with PAD. This is a retrospective small cohort analysis of patients with diabetes and the long-term treatment effect of spinal cord stimulation.MethodsAs the main outcome of the study, we evaluated the survival and amputation of 13 diabetic patients with chronic lower-limb ischemia who were not eligible for surgical or interventional therapy. Secondary outcomes included ankle-brachial index (ABI), ischemic pain intensity, quality of life, use of analgesic medications and skin wound outcomes analyzed during long-term follow-up.ResultsBetween January 2010 and January 2017, 13 patients underwent SCS implantation in our vascular center. At 1-year follow-up, the limb salvage rate was 92.3% (12 of 13 patients), and limb ulcers healed in 75% of patients (6/8). No patient died during the one-year follow-up. A total of 4 of patients (31%) experienced major amputation during long-term follow-up, all of them were Fontaine stage IV. Pain intensity and quality of life improved significantly at 6-month follow-up (p < 0.05). ABI measurements were unaffected by SCS treatment. There were no complications related to the procedure or device.ConclusionsSCS is a promising treatment option for diabetic patients unsuitable for endovascular or surgical revascularization. The method improves limb survival in diabetic patients with critical limb ischemia, provides significant pain control, and improves patients' quality of life. However, more studies are needed to clarify the indications for SCS and clarify its effects on the vascular system.

Evaluation of Peripheral Circulatory Changes Following Hydrotherapy and Controlled Physical Training in Patients with Atherosclerotic Lower Limb Ischemia

Numerous studies highlight the significant role of exercise therapy in patients with peripheral artery disease (PAD), emphasizing how regular physical exercise enhances vascular endothelial function and promotes metabolic adaptations in skeletal muscles, ultimately improving walking performance. There are currently discussions in the medical world on optimizing noninvasive therapy to prevent the development of lower limb ischemia. This study aimed to assess the impact of a supervised training program combined with whirlpool massage treatment on improving peripheral circulation and physical performance in patients suffering from peripheral artery disease. Methods: One hundred participants (both male and female) aged between 39 and 79 years old (60.0 ± 11.6) were included in the analysis, all diagnosed with peripheral circulation disorders. The participants were assigned to two groups. The study group received 10 whirlpool treatments of the lower limbs and a personalized training program. The control group only participated in the training sessions. Pre- and post-intervention evaluations included impedance plethysmography and the six-minute walk test (6MWT). Results: Assessing the results of local flow parameters, after the procedures, a statistically significant increase in the pulse wave amplitude (PAmpl, p < 0.001) and systolic slope (PSlope, p < 0.001) values was found, as well as a statistically significant decrease in the crest time (CT, p < 0.001) and propagation time (PT, p = 0.007) values in the study group, which indicates an improvement in blood flow in the peripheral circulation. Also, in the 6 min walk test, a statistically significant increase in the walking distance was noted in the study group after the procedures. Conclusions: Physical training, combined with whirlpool massage treatment, has a beneficial effect on improving peripheral blood flow assessed by impedance plethysmography, as well as patients’ tolerance to physical exercise. The inclusion of hydrotherapy as part of cardiovascular rehabilitation protocols in patients with peripheral ischemia is a promising form of conservative treatment.

Application of Bilateral Cerebral Perfusion + Balloon Occlusion of Descending Aorta + Antegrade Perfusion of Lower Body in Debakey Type I Aortic Dissection.

To evaluate the efficacy of a new perfusion method in DeBakey Type I aortic dissection surgery, with the goal of enhancing thorough organ protection and optimising patient outcomes. Descriptive study. Place and Duration of the Study: Department of Thoracic and Cardiovascular Surgery, The First Affiliated Hospital of the University of South China, from January 2020 to December 2021. Thirty-two patients undergoing total aortic arch replacement with descending aortic stenting were included in the study. The new perfusion method involved a combination of bilateral selective cerebral perfusion, descending aortic balloon occlusion, and antegrade lower body perfusion. Lower limb ischaemic complications and mortality rate were the main outcome measures. Surgical procedures and patient data were collected and analysed. No cases of paraplegia, intestinal necrosis, or lower-limb ischaemia were observed. The new perfusion method effectively protected lower-body organs, with a short duration of lower-body ischaemia during surgery. The overall mortality rate was 3.13%, and postoperative complications were minimal, resulting in satisfactory survival rates. The combination of perfusion techniques, including bilateral selective cerebral perfusion, descending aortic balloon occlusion, and anterograde lower body perfusion, proved effective in improving the outcomes for DeBakey Type I aortic dissection surgery. Further research is needed to confirm the long-term benefits of this approach. DeBakey type I aortic dissection, Descending aortic balloon blockade, Lower body anterograde perfusion, Bilateral selective cerebral perfusion.

The calf muscle strength correlation with the severity of ischemia and outcomes in patients with chronic lower limb ischemia

The calf muscle strength correlation with the severity of ischemia and outcomes in patients with chronic lower limb ischemia

Catheter-Directed Arterial Thrombolysis with a Low-Dose Recombinant Tissue Plasminogen Activator Regimen for Acute Lower Limb Ischemia-Results of the First Regional Registry of Acute Limb Ischemia in Romania.

Acute limb ischemia is a limb-threatening condition that is associated with a high degree of mortality and morbidity, with the latter related to acute kidney injury and rhabdomyolysis that can rapidly lead to multiple organ failure. The aim of this study was to assess the efficacy and safety of catheter-directed arterial thrombolysis in acute lower limb ischemia in the Department of Vascular Surgery, Timișoara, Romania. A total of 158 patients (114 males-72.15% and 44 females-27.85%) with symptoms of acute lower limb ischemia were admitted and treated with catheter-directed arterial thrombolysis following our protocol. The amputation-free survival rate at 1 month after the thrombolysis was 82.3%, and at 6 months it was 77.85%. The performance of additional procedures to obtain distal perfusion was predictive of an improved outcome at 30 days. The estimated survival rate at 6 months was 84.81% (SE 0.02). The mean survival time was 158.74 days. We recommend the usage of a thrombolytic regimen in patients with a life expectancy of more than 6 months, even in Rutherford stage IIb patients, if there is no major impairment in the sensorial and mobility function of the ischemic leg.

Best evidence summary of prevention and management of lower limb ischemia in patients with veno-arterial extracorporeal membrane oxygenation

To provide evidence-based recommendations for the prevention and management of lower limb ischemia in veno-arterial extracorporeal membrane oxygenation (VA-ECMO) patients during treatment according to search, evaluate, and summarize the best evidence on the prevention and management of lower limb ischemia in patients with VA-ECMO. Based on the PIPOST framework (population, intervention, professional, outcome, setting, and type of evidence), an evidence-based question was formulated. A systematic search was conducted according to the "6S" evidence pyramid model in both domestic and international databases, as well as professional association websites, for all evidence related to the prevention and management of lower limb ischemia in VA-ECMO patients (aged ≥18 years). The types of evidence included clinical decisions, guidelines, expert consensus, systematic reviews, evidence summaries, and original studies. The search was conducted from the construction of the databases to February 2024. Two researchers independently conducted a literature quality evaluation, extracted and summarized evidence from the studies that met the quality criteria. A total of 13 articles were included, consisting of 3 clinical decisions, 3 guidelines, 3 expert consensus, 3 systematic reviews, and 1 randomized controlled trial. A total of 18 pieces of evidence in 7 dimensions were summarized, including risk factors of VA-ECMO lower limb ischemia, evaluation before catheterization, evaluation and monitoring during treatment, prevention of lower limb ischemia, treatment of lower limb ischemia, management of distal perfusion catheter (DPC), and monitoring after VA-ECMO weaning. This evidence summary provides evidence-based recommendations for the prevention and management of lower limb ischemia in VA-ECMO patients, aiming to assist clinical healthcare professionals in developing tailored strategies for the prevention and management of lower limb ischemia based on during VA-ECMO support.

Oxygen-generating hydrogels combined with electrical stimulation: A dual approach for promoting diabetic wound healing

Chronic wounds resulting from hyperglycemia and hypoxia are common complications in diabetic patients, posing significant challenges for clinical treatment. In this study, we developed a hydrogel (PVNP-SP) using [VBIM]Br, NIPAM, PEGDA, and spirulina, which exhibited strong antioxidant properties. The incorporation of [VBIM]Br endowed the hydrogel with electrical conductivity, allowing it to activate voltage-gated ion channels under an external electric field, thereby promoting cell survival and migration. The hydrogel also enhanced cellular antioxidant capacity by providing sustained oxygenation, inhibiting HIF-1α nuclear translocation, and activating the Nrf2/HO-1 pathway. Notably, in a chronic wound model, the combined effects of oxygen production and electrical stimulation from the PVNP-SP hydrogel significantly reduced wound inflammation, promoted collagen deposition and angiogenesis, and facilitated early wound closure. This therapeutic strategy, which mitigates hypoxia while integrating electrical stimulation, offers a highly effective strategy for improving chronic wound healing in diabetic patients. Statement of significanceInspired by photoautotrophic organisms, we combined microalgae with a conductive hydrogel and we demonstrated the synergistic promotion of chronic wound healing by electrical stimulation combined with microalgae oxygen-producing hydrogel. The approach of combining microalgae hydrogel patches with electrical stimulation demonstrates the feasibility of delivering oxygen to tissues while combining electrical stimulation for synergistic tissue repair. The hydrogel is easy to fabricate and handle, and may be suitable for a variety of treatments, such as myocardial infarction, lower limb ischemia, and drug delivery. The potential applicability of this hydrogel in a variety of treatments suggests that it has promising applications in regenerative medicine.

An Innovative Delivery System of Oxygen-Releasing Nanospheres and Self-Healing Hydrogels Enhances the Therapeutic Effectiveness of Bone Marrow Mesenchymal Stem Cells for Chronic Limb-Threatening Ischemia.

Bone marrow mesenchymal stem cells (BMSCs) have emerged as promising candidate for postoperative therapeutics in chronic limb-threatening ischemia (CLTI). Nevertheless, their effectiveness is limited by their low survival rate and impaired functionality in the ischemic microenvironment. To overcome these challenges, we have devised an innovative delivery approach to support the utilization of BMSCs in CLTI therapy. We synthesized oxygen-releasing nanospheres and self-healing hydrogels. The in vivo functionality of the hydrogel-nanosphere delivery system was evaluated via a multimodality animal live imaging system. A unilateral lower limb ischemia model was established in mice, and a delivery system loaded with BMSCs was administered. The experimental groups included normal mice, ischemic mice, ischemic mice treated with BMSCs in PBS, and ischemic mice treated with BMSCs in the delivery system. Blood perfusion was quantitatively measured via a laser doppler flowmeter (LDF). Immunofluorescence, Masson's trichrome staining, immunohistochemistry and enzyme-linked immunosorbent assay (ELISA) were also used. For cell viability analysis 80 μg.mL-1 was considered the optimal concentration for cell survival. In vivo, 18 days after injection, the cell membrane fluorescence signal in the delivery system was significantly greater (5.65510±8.2268) p/s/cm²/sr than that in the other groups (p=0.043). Ischemic mice treated with BMSCs in the delivery system presented an improved limb salvage rate (0.926±0.12)% compared with that of ischemic mice treated with BMSCs in PBS (0.841±0.029)% at the 5th week after ischemia establishment (p=0.0033). Our findings suggest that the survival time of BMSCs is prolonged in this innovative delivery system. The combination of nanospheres and hydrogels effectively restored vascular blood perfusion while exerting minimal toxicity on BMSCs. This novel approach combining oxygen-releasing nanospheres and self-healing hydrogels as a delivery system represents an advancement in enhancing the functionality of BMSCs to treat CLTI.

A Case of Bilateral Lower Limb Ischemia Due to Endograft Collapse From Type B Acute Aortic Dissection.

Endograft collapse caused by aortic dissection is rare, but it might cause critical complications and sometimes lead to death. We present a case of bilateral lower limb ischemia caused by endograft collapse due to type B acute aortic dissection (TBAD). A 70-year-old man with an abdominal aortic aneurysm (AAA) that was treated by endovascular aortic aneurysm repair (EVAR) 17 days prior returned to our hospital due to chest pain and bilateral lower limb paleness. Contrast-enhanced computed tomography (CT) showed an aortic dissection extending from the origin of the left subclavian artery to the terminal aorta. The main body of the endograft was compressed and the aneurysm was perfused by the false lumen. Additionally, the right leg of the endograft was occluded and the left one was collapsed. The patient was treated with axillo-bifemoral bypass without any lower limb sequela. However, contrast-enhanced CT performed at 2 months after the onset of the TBAD showed that the main body of the endograft was still collapsed, and the aneurysm was perfused by the false lumen of the dissection; thus, open AAA repair was performed. The postoperative course was uneventful and the patient was discharged without any complications. We successfully treated the patient with bilateral lower limb ischemia caused by endograft collapse due to TBAD after EVAR. The treatment should be considered on a case-by-case basis and an extra-anatomical revascularization is one of the good treatment options.

Comparative insights into type non-A non-B vs type B acute aortic syndromes and their blood pressure management: a monocentric, retrospective, 11-year study

Abstract Background Acute aortic syndromes (AAS) are classified either as type A, if the ascending aorta is involved, or as type B, if only the descending aorta is; AAS affecting the aortic arch, alone or in combination with the descending aorta, have recently been classified as type non-A-non-B (NANB). Few and discordant data are available about the differences between type B and type NANB AAS, especially in terms of presentation, management and prognosis. Little evidence also exists about the effects of blood pressure (BP) management, peaks and variability on in-hospital outcomes in such context. In particular, the largest international AAS registry suggests a comparable course and prognosis, while a recent meta-analysis indicates a poorer clinical outcome with higher rate of complications, need of invasive treatment and mortality in the case of type NANB AAS. Methods We conducted a monocentric, observational, analytical, retrospective registry study including all patients ≥ 18 years old admitted to our tertiary referral hospital with a diagnosis of type B or type NANB AAS from January 2011 to December 2021. Epidemiological, clinical, operative and outcome data were analyzed by comparing type B and type NANB AAS patients. We also focused on systolic and diastolic BP, in terms of both peak values as well as BP variability (BPV); BPV was defined as the difference between the peak and the through value on a certain day. Blood pressure variables were analyzed in relationship with mortality and the failure of an initial conservative management. Results 274 type B and 44 type NANB AAS patients were enrolled. The only significant differences between the two groups were a higher rate of pre-operative complications in type NANB patients (p=0.002) resulting in a higher rate of invasive management (p=0.005), particularly as failure of an initial conservative strategy (p=0.018). However, comparable rates of post-operative complications and in-hospital mortality (overall 7%) were observed. In the overall population, lower limb ischemia, ST segment depression, and post-operative visceral ischemia were associated with higher in-hospital mortality. Peri-aortic effusion was independently associated with failure of conservative management, whereas diagnosis of intramural hematoma (as opposed to other subtypes of AAS) appeared to be protective. Among all BP variables (including anti-hypertensive treatment intensity and daily systolic or diastolic BP peaks and variability), only peak systolic BP on day 5 was found to be non-independently associated with a higher risk of in-hospital mortality and failure of an initially conservative strategy. Conclusions In our study type NANB AAS were more often complicated and treated invasively than type B AAS, while having the same rates of post-operative complications and overall mortality. BP peaks had only a minor effect on outcomes, while BPV and BP management intensity did not have any significant impact.OutcomesBlood Pressure

Vascular complications in patients with peripheral veno-arterial extracorporeal membrane oxygenation: clinical-echocardiographic characteristics and predictors

Abstract Introduction Veno-arterial Extracorporeal membrane oxygenation (VA ECMO) is a salvage intervention in patients with cardiogenic shock (CS), and cardiac arrest (CA) refractory to standard therapies. Lower limb ischemia associated with peripheral VA ECMO is frequent, and is considered a serious complication with a significant impact on the morbidity and mortality. Purpose The aim of this study was to describe the clinical-echographic parameters and analyze predictors related to vascular complications in patients with peripheral VA ECMO. Methods The study was a single-center cohort analysis. It included all consecutive adult patients with peripheral femoro-femoral VA ECMO due to refractory cardiogenic shock (CS) or cardiac arrest (CA) between March 2014 and December 2022. Patients with central cannulation were excluded. The primary endpoint was evidence of vascular complications resulting in surgical intervention. A multivariate logistic regression model was used to adjust for variables of interest. Results The study included 83 patients (65± 12 years, 54% male). The main previous diagnosis was necrotic ischemic cardiomyopathy (33%), and the most frequent indication was postcardiotomy (40.9%), mainly in SCAI D (85.5%). Cardiopulmonary resuscitation was performed in 18.1%. Femoro-femoral cannulation was percutaneuos in 95.2%. Most patients had intra-aortic balloon pump (87.1%) and distal percutaneous cannula (88.8%). A total of 18 patients presented vascular complications (21.7%): 2 patients (11.1%) amputation, 5 patients (27.7%) compartment syndrome requiring fasciotomy, 9 patients (50.0%) thrombectomy, and 2 patients (11.1%) a surgical resolution post decannulation due to AV fistula. The median duration of VA ECMO was 5 days (IQR 2-8). Among the ultrasound variables, the systolic peak velocity (SPV) in the distal territory (tibioperoneal segment) had a median of 22 cm/sec (IQR 10-30). Pulsatile spectral Doppler flow in the cannulated limb was evidenced in 42 patients (50.6%) of total population, and only in 3 patients (16.6%) with vascular complications. The survival rate from VA ECMO was 57.8%, and the survival rate to discharge 42.1%. In-hospital mortality of patients with or without vascular complications did not show statistically significant differences (54.2 % vs 58.2 %, p= 0.26). After multivariate analysis, distal territory SPV less than 20 cm/sec (OR: 2.1, 95%CI: 1.3 – 12.1, p: 0.03), as well as history of previous vascular disease, were associated with a higher number of vascular complications (OR: 2.5, 95% CI: 1.5 – 10.1, P; 0.02). Conclusions Vascular complications in patients with femoro-femoral VA ECMO remain frequent and constitute an important cause of morbidity. Decreased peak systolic velocities in the cannulated tibio-peroneal territory, as well as a history of previous vascular disease were significantly associated with a higher rate of vascular complications.

Catheter-Directed Thrombolysis for (Not Immediately) Threatened Acute Lower Limb Ischemia: Clinical Outcome and Efficacy.

The objective of this study was to examine the short- and midterm outcomes of catheter-directed thrombolysis (CDT) for acute lower limb ischemia (ALI), classes Rutherford 1 and 2, with specific attention to functional outcome. This retrospective study included patients with ALI treated with CDT from 2 vascular centers between May 2018 and April 2021. Cases were analyzed in groups according to the Rutherford (1 and 2) classification. The primary endpoint was functional outcome during follow-up, assessed by Rutherford's chronic limb ischemia classification. Functional outcomes over time were analyzed by generalized estimating equations. Kaplan-Meier analysis was used to estimate reintervention, amputation, survival, and reintervention-free survival rates. Two hundred cases were included (Rutherford 1, n = 51; Rutherford 2, n = 149). Total median treatment duration was 27 hours in the Rutherford 1 group and 39 hours in the Rutherford 2 group (P= 0.120). Initial clinical success was high (Rutherford 1, 82% vs Rutherford 2, 89%; P= 0.253). Complications were comparable between the 2 groups: major bleeding 8% vs 10% (P= 0.634), major amputation 4% vs 7% (P= 0.603), and mortality 6% vs 6% (P= 0.967). Median follow-up was 32 months (0-63 months). During follow-up, there was a high number of reinterventions (43%) and amputations (20%) in patients with Rutherford 1 limb ischemia, which was comparable to patients with Rutherford 2 limb ischemia. Fifty-six percent of the patients with Rutherford 1 limb ischemia reaching 2 years of follow-up were asymptomatic, 20% had mild and 16% had moderate to severe claudication. Initial clinical success following CDT and not immediately threatened ischemia at presentation are associated with improved functional outcomes during follow-up (P < 0.001 and P= 0.009, respectively). In our cohort, CDT was effective in reestablishing arterial flow for not immediately threatened ALI. Patients with Rutherford 1 limb ischemia who receive CDT had a more favorable functional outcome than patients with more severe limb ischemia (Rutherford 2). However, reinterventions were required frequently, and there was a substantial risk of complications. Acute lower limb ischemia (ALI) does not immediately jeopardize limb survival in patients with Rutherford 1 limb ischemia but can induce disabling claudication. In such patients, catheter-directed thrombolysis (CDT) is often performed to improve functional outcome. However, previous reports warned about the complications of CDT, and so far, mid- and long-term functional outcomes have not been reported. This study, in which a large cohort of patients with ALI was included, demonstrates a high technical success of CDT for not immediately threatened ALI with more favorable functional outcomes when compared with those with threatened limbs. Nevertheless, major complications pose a serious risk, and the need for reinterventions in the long term is high.

Outcomes of Catheter Directed Thrombolysis for Early and Late Re-occlusions in Acute Lower Limb Ischemia.

Acute lower limb ischemia (ALI) is a sudden decrease in arterial limb perfusion due to an arterial blockage, threatening limb and life. Catheter-directed thrombolysis (CDT) is a minimally invasive procedure to remove such obstructions. However, approximately one-third of patients endure a re-occlusion after successful CDT. This study aimed to investigate the short- and long-term outcomes of CDT for early (<1 year) and late (>1 year) re-occlusions. This retrospective multicenter study reviewed patients from 2 medical centers with an acute arterial re-occlusion of the lower limb after successful CDT between December 1996 and April 2021. The primary endpoints were angiographic success, defined as thrombus dissolution over 95% with outflow to at least 1 crural artery, and clinical success, defined as a score of ≥1 on the Rutherford scale for assessing changes in clinical status. Secondary endpoints included bleeding complications, patency, amputation, and mortality. Kaplan-Meier analyses were used to estimate patency, survival, and freedom from amputation. Seventy-seven cases were included, with 52 early re-occlusions (<1 year) and 25 late re-occlusions (>1 year). The median time to re-occlusion since the last CDT treatment was 4 months in the early re-occlusion group and 24 months in the late re-occlusion group. Angiographic success was achieved in 73% of early and 64% of late re-occlusions. Clinical success rates were 80.8% for the early and 80.0% of the late re-occlusion cases. Major bleeding occurred in 2% of the early and 8% of the late re-occlusion group. Patients were followed up until symptoms or signs of limb ischemia were resolved, with a median follow-up time of 15 months for the early and 22 months for the late re-occlusion group. During follow-up, secondary re-occlusions were observed in 59.6% of the early and 44% in the late group. Cumulative amputation rates at 1, 5, and 8 years were 36%, 36%, and 52% for early and 18%, 30%, and 30% for the late re-occlusions, respectively. In our experience, CDT is an effective short-term revascularization strategy for the majority of patients with both early and late re-occlusions. Long-term results are limited by secondary re-occlusions and limb loss. Catheter-directed thrombolysis (CDT) is a well-established treatment for acute lower limb ischemia (ALI). Re-occlusions after successful treatment are, however, observed in almost a third of the patients. Yet, the outcomes of CDT for re-occlusions for patients who were previously treated with CDT are not well known. This study showed that CDT is effective in achieving revascularization in cases of early and late re-occlusion after treatment for ALI, but the risk for further re-occlusions is high. Future studies should focus on maintaining patency after successful CDT for ALI.

Leukotrienes E4 and B4 and vascular endothelium – New insight into the link between vascular inflammation and peripheral arterial

Leukotrienes are proinflammatory mediators that participate in the process of atherogenesis and contribute to the development of symptomatic peripheral arterial disease. The aim was to evaluate the relationship between leukotriene E4 (LTE4) and B4 (LTB4) with parameters reflecting endothelial vascular function in patients with chronic lower limb ischemia. This prospective observational study enrolled 50 consecutive patients undergoing endovascular treatment due to chronic lower limb ischemia (Rutherford 3). All participants were followed-up for one year (after 1, 3, 6 and 12 months), with a sequential assessment of urinary LTE4 and LTB4, as well as measures of endothelial and vascular function: Flow-Mediated Dilatation (FMD), Intima-Media Thickness (IMT), corrected Augmentation Index (AI75), Shear Rate (SR), Ankle-Brachial Index (ABI), Toe-Brachial Index (TBI). There was a significant relationship between LTE4 and measures of vascular function: FMD (R2 = 0.69, P < 0.001), IMT (R2 = 0.12, P < 0.01), AI75 (R2 = 0.43, P < 0.001), SR (R2 = 0.48, P < 0.001). Similar findings were noted for LTB4: FMD (R2 = 0.47, p < 0.001), IMT (R2 = 0.23, P < 0.001), AI75 (R2 = 0.61, P < 0.001) and SR (R2 = 0.33, P < 0.001). Alterations in parameters were significantly related: ΔLTE4 vs ΔFMD(R2 = 0.63, P < 0.001), ΔSR (R2 = 0.42, P < 0.001) and ΔLTB4 vs AI75(R2 = 0.40, P < 0.001), SR(R2 = 0. 29, P < 0.001). We conclude, that increasing concentrations of LTE4 and LTB4 are associated with impairment of vascular and endothelial function, which may lead to worse endovascular treatment clinical outcomes.

Extracorporeal Off-Pump Antegrade Cerebral Perfusion in Reconstructive Surgery for Type A Aortic Dissection With Cerebral Malperfusion.

Introduction Type A aortic dissection (TAAD) is a life-threatening condition that often leads to cerebral malperfusion (CM), a severe complication that can result in permanent neurological damage. Traditionally, a cardiopulmonary bypass (CPB) with selective antegrade cerebral perfusion (ACP) is employed during aortic arch reconstruction to protect cerebral circulation. However, the use of CPB carries inherent higher risks, including embolic events, hypothermia, and interrupted cerebral perfusion, especially in patients with CM. This study evaluates an innovative off-pump extra-corporeal ACP technique using an axillo-axillary shunt to provide uninterrupted bihemispheric cerebral perfusion during branch-first stage total aortic arch replacement (BF-TAR)for TAAD with CM; the shunt depends on cardiac contradiction to transfuse blood from the donor axillary artery to the recipient axillary artery, which then flows to through the carotid and vertebral arteries to the brain. Methods Between 2021 and 2023, 18 patients with TAAD complicated by CM underwent BF-TAR; the novel axillo-axillary shunt technique was employed for ACP because of the risks of ischemic neurologic injury. Outcomes measured included operative mortality, neurological complications, cardiopulmonary bypass times (measured after completion of the branch-first stage), and overall morbidity. Results The axillo-axillary shunt provided stable, continuous ACP in all patients. No new permanent neurological deficits were observed. Five (27.8%) patients experienced transient neurological symptoms such as blurred vision, dizziness, and confusion, which resolved within 48 hours. Operative mortality was 5.6% (1 patient), and minor complications included transitory lower limbs ischemia in 3 patients (16.7%) and deep sternal wound infection in 1 patient (5.6%). All transitory complications were managed by "watchful waiting". The mean CPB time was 145.3 ± 48.6 minutes, while the mean cross-clamp time was 100.6 ± 17.4 minutes, which was better than the average of 227 ± 32 minutes and 147 ± 23 minutes reported in other studies. Postoperative imaging confirmed well-reconstructed aortic arches with no residual malperfusion or graft-related complications. Conclusion The off-pump axillo-axillary shunt technique provides a safe and effective method for maintaining continuous bihemispheric cerebral perfusion during total aortic arch replacement in patients with TAAD complicated by CM. This approach minimizes the risks associated with CPB, including embolic events and interrupted cerebral perfusionwhile achieving favorable neurological and surgical outcomes. Further studies with larger cohorts and longer follow-ups are warranted to validate the long-term benefits of this innovative technique.

Interobserver and inter-modality concordance of quiescent interval slice selective magnetic resonance angiography and CT angiography in assessment of critical lower limb ischemia

BackgroundWe evaluated the noncontrast MRA as an alternate method to CT angiography in assessment of patients with lower limb ischemia, 30 patients were included in a prospective cohort study; they underwent quiescent interval slice selective magnetic resonance angiography (QISS-MRA) and computed tomographic angiography (CTA). The assessment of images was evaluated by two independent consultants. The overall subjective image quality, interobserver and intermodality concordance were calculated.ResultsThe median acquisition time in QISS-MRA was 20 min (range 18–30 min), The overall subjective image quality was rated similarly with QISS-MRA (3.13 [95% CI 2.84–3.42]) and CTA (3.23 [95% CI 2.94–3.52]; p = 0.08) with interobserver concordance for lesion ratings in QISS-MRA reached (κ = 0.987 (SD 0.006)), while for CTA it was (κ = 0.99 (SD 0.006)), while the intermodality concordance between QISS-MRA and CTA in lesion ratings were calculated on a per segment basis and was (κ = 0.944 (SD 0.013)) for reader 1 and (κ = 0.947 (SD 0.013)) for reader 2, with sensitivity 100% and specificity 97.6%ConclusionsQISS-MRA is a reliable modality for assessment of patients with critical limb ischemia.

Mechanical Thrombectomy by Rotarex® Device versus Chemical Thrombolysis in The Management of Acute Lower Limb Ischemia (prospective randomized study)

Abstract Background Acute limb ischemia (ALI) is one of the most frequent causes for amputation and a potentially life-threatening condition, affecting approximately 1.5 persons per 10 000 per year worldwide. Aim of the Work To compare safety (peri operative complications) and efficacy (the success rate, the patency rate and the limb salvage rate) of Percutaneous Mechanical Thrombectomy (PMT) versus Catheter Directed Thrombolysis (CDT) in the management of acute thrombotic lower limb ischemia. Patients and Methods This prospective randomized study was conducted on 50 patients with acute thrombotic lower limb ischemia (Rutherford class I, II A) at Ain Shams University Hospitals and Helwan University Hospitals in the period between September 1st, 2021, and August 31st, 2023. Patients were randomized into two groups: Group A: included 25 patients, who were treated with percutaneous mechanical thrombectomy using the Rotarex™S device (Becton, Dickinson and Company, New Jersey, USA) and Group B: included 25 patients, who were treated with catheter directed thrombolysis using drug Actilyse® (Boehringer Ingelheim, Ingelheim am Rhein, Germany) and catheter Fountain® Infusion System with Squirt® (Merit Medical Systems, Inc. California, USA). Results In our study, we achieved technical success rate 96% (n = 24) and 80% (n = 20) in group A and group B respectively. Regarding peri operative complications, group A showed 2 cases (8%), (1 perforation and 1 distal embolization / trash foot), and group B showed 2 cases (8%), (1 intracranial hemorrhage and 1 puncture site pseudo aneurysm). 30-day mortality wasn’t reported in any case in group A, while 2 cases were reported in group B. At 1 month follow-up, primary patency rate was 84.0% (21/25) and 81% (17/21) in group A and group B respectively and this rate declined to 62.5% (15/24) and 55.6% (10/18) at 1 year follow up. Late complications (major amputations) were recorded, 1 patient in group A and 2 patients in group B had below knee amputation, non of the patients had above knee amputation in group A, while 3 patients had above knee amputation in group B. Conclusion Despite that the results of percutaneous mechanical thrombectomy and catheter directed thrombolysis were comparable, percutaneous mechanical thrombectomy is considered more safe and efficient technique. Percutaneous mechanical thrombectomy was done in single session. PMT had lower mortality and morbidity, higher limb salvage and patency rate than CDT, but in PMT special attention should be given to the potential for distal embolism.

Directional Atherectomy for Critical Lower Limb Ischemia: A Retrospective Observational Study.

Chronic arterial obstructive disease of the lower limbs is a significant global health issue. Directional atherectomy offers advantages in treating critical ischemia. The objective of this study is to determine the clinical outcomes of patients with critical ischemia who underwent directional atherectomy using the TurboHawkdevice. A retrospective review was conducted at Alma Mater Hospital in Medellín, Colombia, on all medical records of patients with critical limb ischemia (Rutherford Classes V and VI) who underwent directional atherectomy for infra-inguinal arterial disease. A total of 42 atherectomies were performed in 41 patients, with 61% classified as Rutherford V and 24.4% as Rutherford VI. The average lesion length to be treated was 60 mm. Calcifications were found in 45.2% of cases, and predilatation angioplasty was used in 42.9% of cases. Atherectomy sites included femoropopliteal segment (40%), superficial femoral (29%), infrapopliteal vessels (14.2%), and more than one vessel in 50% of cases. Technical success was achieved in 78.6% of cases and procedural success in 97.6%, and the need for adjunctive conventional balloon angioplasty was 21.4%, while drug-coated balloon angioplasties were performed in 50% of limbs. The overall complication rate was 14.4%, with embolism at 4.8%, dissection at 4.8%, puncture at 2.4%, and perforation at 2.4%. The average follow-up duration was 12 months, and major amputations were required in 23.8% of cases. Improvement in ankle-brachial index to ≥0.1 was seen in 77% of limbs. Limb survival at 30 days was 85%, and at 90 days, it was 83%. The overall survival rate in the study was 79%. Directional atherectomy is a safe alternative for managing critical ischemia in Rutherford V and VI patients.

Acute lower limb ischemia caused by repeat deployment of vascular closure device.

Vascular closure devices are used to facilitate faster hemostasis and earlier ambulation, improve patient comfort, and reduce length of hospital stay after percutaneous endovascular procedures. However, their use may rarely be associated with limb ischemia due to endothelial damage and arterial thrombosis. This report illustrates the case of a patient who experienced acute lower limb ischemia due to superficial femoral artery occlusion caused by repeat closure with Angio-Seal vascular closure device within 30 days in a small-caliber superficial femoral artery. The patient was surgically treated by vascular repair with a synthetic graft, and remains symptom-free in 3-year follow-up. Repeat deployment of vascular closure devices in the same access site within a period of 30 days may cause acute limb ischemia due to arterial thrombosis, especially in patients with small-caliber arteries, even in the absence of evident risk factors.

Quality of Life Predictors in Patients with Acute Lower Limb Ischemia Quality of Life in Acute Limb Ischemia

ObjectiveWhile existing literature has established factors associated with improved health-related quality of life (HRQOL) in patients with chronic limb-threatening ischemia, similar work has not been done in individuals with acute lower limb ischemia (ALLI). This study aims to identify the factors associated with HRQOL in patients presenting with ALLI. MethodsUsing a prospectively collected registry, all patients who received treatment for ALLI between May 2016 and July 2023 at a quaternary medical center were identified and invited to complete two HRQOL questionnaires: the VascuQoL-6 and the EQ-5D-5L. Simple linear regression followed by multivariate analysis using multiple linear regression were used to determine the patient variables independently associated with HRQOL. ResultsOf the 216 eligible patients treated for ALLI during the study period, 47 (20%) of patients with a mean age of 58 ± 10 years completed the HRQOL questionnaires. Questionnaires were completed at a median time of 16.5 months after the episode of ALLI. On multiple linear regression, higher age was associated with higher VascuQoL-6 (p=0.037) and EQ-5D-5L (p=0.041) scores, while hypertension and non-ambulatory status were significant predictors of lower VascuQoL-6 (p=0.006, p=0.013) and EQ-5D-5L (p=0.009, p=0.026) scores. Any ambulation had a significantly higher HRQOL compared to non-ambulatory status, but no significant HRQOL difference was observed between patients with any type of ambulation (unhindered ambulation, ambulation with pain, and ambulation using a prosthesis). ConclusionThis study demonstrates that the ability to ambulate after ALLI, and not amputation per se, is an important predictor of HRQOL. As such, early rehabilitation strategies should be a focus of post-ALLI care. Further exploration of factors that shape HRQOL after ALLI is needed.