Management Of Acute Limb Ischemia Research Articles

Acute Limb Ischemia Secondary to Thrombosis in Persistent Sciatic Artery: A Case Report and Review of Management Strategies

Persistent sciatic artery (PSA) is a rare vascular anomaly with potential for significant vascular complications. We present a case of a 39-year-old male with acute limb ischemia secondary to thrombosis in a PSA, highlighting the challenges in diagnosis and management. Despite the absence of aneurysmal formation, the patient presented with severe pain and absent distal pulses, prompting urgent intervention. Computed tomography angiography revealed thrombosis extending into the left common iliac artery. Catheter-directed thrombolysis (CDT) was successfully performed, resulting in complete resolution of the thrombus and restoration of limb perfusion. The patient experienced symptomatic relief postoperatively and regained ambulatory function. This case underscores the importance of considering PSA in the differential diagnosis of acute limb ischemia and highlights CDT as an effective treatment modality. Further research is needed to optimize the management of acute limb ischemia associated with PSA and to evaluate long-term outcomes.

Short-term outcomes of endovascular management of acute limb ischemia using aspiration mechanical thrombectomy.

Management of acute limb ischemia (ALI) has seen greater utilization of catheter-based interventions over the last two decades. Data on their efficacy is largely based on comparisons of catheter-directed thrombolysis (CDT) and open thrombectomy. During this time, many adjuncts to CDT have emerged with different mechanisms of action, including pharmacomechanical thrombolysis (PMT) and aspiration mechanical thrombectomy (AMT). However, the safety and efficacy of newer adjuncts like AMT have not been well established. This study is a retrospective analysis of the contemporary management of ALI comparing patients treated with aspiration mechanical thrombectomy to patients treated with the more established CDT adjunct, pharmacomechanical thrombolysis. Patients undergoing peripheral endovascular intervention for ALI using an adjunctive device were identified through query of the Vascular Quality Initiative (VQI) Peripheral Vascular Intervention (PVI) module from 2014 to 2019. Patients with a nonviable extremity (Rutherford ALI Stage 3), prior history of ipsilateral major amputation, popliteal aneurysm, procedures that were deemed elective (>72h from admission), procedures that did not utilize an endovascular adjunctive device, and patients without short-term follow-up were all excluded from analysis. The primary outcome was a composite outcome of freedom from major amputation and/or death in the perioperative time period. We identified 528 patients with Rutherford ALI Stage 1 or 2 who were treated with an endovascular adjunct. 433 patients did not undergo aspiration mechanical thrombectomy (no AMT group) and 95 patients did undergo aspiration mechanical thrombectomy (AMT group). The amputation-free survival across all patients was 93.4%. There were significant differences in demographic, comorbidity, and treatment variables between groups (e.g., gender, prior percutaneous coronary intervention (PCI), history of prior peripheral artery disease intervention, and history of prior infra-inguinal PVI), so a propensity score matched analysis was included to account for these group differences. In the propensity score matched analysis, there was no significant difference in major amputation (AMT 7.4% vs no AMT 3.2%, p = 0.13) or death (AMT 95.8% survival vs no AMT 98.4% survival, p = 0.23) with the use of aspiration mechanical thrombectomy. However, there was significantly worse amputation-free survival with the use of aspiration mechanical thrombectomy (AMT 88.4% vs no AMT 95.3%, p = 0.03). On multivariate analysis, prior supra-inguinal bypass (OR 4.85, 1.70-13.84, p = 0.003), Rutherford ALI Stage 2B (OR 3.13, 1.47-6.67, p = 0.003), and aspiration mechanical thrombectomy (OR 2.71, 1.03-7.17, p = 0.05) were associated with the composite outcome. Short-term amputation-free survival rates of endovascular management of acute limb ischemia are adequate across all modalities. However, aspiration mechanical thrombectomy was associated with significantly worse amputation-free survival compared to other endovascular adjuncts alone (i.e., pharmacomechanical thrombolysis). Severe limb ischemia (Rutherford ALI Stage 2B) and prior supra-inguinal bypass were associated with worse amputation-free survival regardless of the choice of endovascular intervention.

Acute limb ischemia in nonagenarians: Characteristics and factors related to outcomes in a single-center consecutive series.

The increasing aging and frailty of the population make the management of acute limb ischemia (ALI) more difficult, with decision-making far from being guided by evidence. The aim of the study was to evaluate the characteristics and results of ALI treatment in nonagenarians. Retrospective analysis of a consecutive series of nonagenarian patients with ALI attended at our institution between 2008 and 2021. The primary outcomes of the study were 1-year limb salvage and survival rates. A total of 102 patients were included (mean age 92.38, 78.4% women). In 83 cases (81.4%) ALI was attributed to embolism, and 19 (18.6%) to acute arterial thrombosis. One-month overall survival was 70.6%. Fifteen patients (14.7%) were treated palliatively, including 8 (53.3%) irreversible ALI with associated malignancy/advanced dementia, 5 (33.3%) with associated cerebral/intestinal ischemia and 2 (13.3%) with aortic occlusion and poor medical condition. None of these patients survived after 10days. The remaining 87 patients (85.3%) were treated with isolated anticoagulation (n=8, 9.1%), primary major amputation (n=1, 1.1%) or revascularization (n=78, 89.6%), including 69 (67.6%) embolectomies, 6 (5.9%) bypass and 3 (2.9%) endovascular techniques. One-year limb salvage and survival rates were 96% and 48%, respectively. Predictive factors of lower survival included anemia (HR=1.81, p=0.014) and ALI severity (HR=1.73, p=0.032), but not cognitive or functional status. Patients surviving the ALI episode had a 1-year survival rate significantly below that of a similar matched population. Although nonagenarians with an ALI are often functionally and cognitively impaired and have a limited life expectancy, most patients need revascularization for limb salvage and this can be done successfully with a low invasive surgery.

Predictors of poor outcomes after lower extremity revascularization for acute limb ischemia.

Acute lower extremity ischemia is one of the most common emergencies in vascular surgery and is a cause of considerable morbidity and mortality. The goal of this study was to evaluate outcomes of revascularization for acute lower extremity ischemia and to determine factors associated with perioperative morbidity and mortality. A total of 354 patients underwent urgent revascularization for acute lower extremity ischemia at an academic medical center between 2014 and 2019. A retrospective review of patients' demographics, comorbidities, etiology and severity of limb ischemia, and procedural characteristics was recorded. Outcomes, including postoperative complications, perioperative limb loss, and mortality, were analyzed. The mean patient age was 69 ± 17years, and 52% were females. 50% of patients presented with Rutherford Class IIb ischemia. Arterial embolization was the most common cause of limb ischemia, seen in 33% of cases. Open surgical revascularization was performed in 241 (68%) patients, while endovascular and hybrid approaches were utilized in 53 (15%) and 60 (17%) cases, respectively. Postoperative adverse events occurred in 44% of patients, including wound complications (11%), cardiac (5%) and pulmonary (16%) complications, strokes (4%), UTIs (10%), renal failure (14%), bleeding (5%), and compartment syndrome (3%). The rate of unplanned return to the operating room was 21%. Major adverse cardiovascular events were seen in 103 (29%) patients and major adverse limb events were seen in 57 (16%) patients. The median length of stay was 10 days (IQR = 4); 49% patients were discharged to skilled nursing facility and 19% were readmitted within 30 days.The rate of amputation during index admission was 10%, and perioperative mortality was 20%. Gender, tibial runoff, and etiology of limb ischemia were independent predictors of limb loss. Women had lower risk of limb loss than men (OR, 0.11; 95% CI, 0.023, 0.38). Poor tibial runoff (one-vessel or absence of flow below the knee) was a significant predictor of limb loss as compared to three-vessel runoff (OR, 14.92; 95% CI, 1.92, 115.88). Aneurysmal disease (OR, 38.35; 95% CI, 3.54, 42.45) and traumatic injuries (OR, 108.08; 95% CI, 8.21, 159.06) were the strongest predictors of amputation as compared to other etiologies of limb ischemia. Multivariate model identified ESRD (OR, 9.2; 95% CI, 1.8-46.3), degree of ischemia (class IIb or higher vs class IIa; OR, 3.5; 95% CI, 1.2-10.6), and age (OR, 1.5; 95% CI 1.1-2.0 for every 10years) as independent predictors of perioperative mortality. Urgent revascularization for management of acute limb ischemia is associated with high morbidity and mortality. Elderly patients with ESRD presenting with severely threatened limbs have especially high risk of perioperative mortality and may not be ideal candidates for limb salvage.

Lung damage reduction due to reperfusion injury of acute lower limb ischemia with and without pentoxifylline and vitamin c combination therapy: histopathological evaluation

Several studies report an incidence of acute limb ischemia of approximately 1.5 cases per 10,000 persons per year. The mortality rate from acute limb ischemia ranges from 15-to 20% and the morbidity rate from 25% by amputation and 5-to 25% to fasciotomy. Revascularization is the main goal in the management of acute limb ischemia. Reperfusion of ischemic limbs can save limbs from amputation, but Ischemia-reperfusion injury can also cause systemic damage in the form of damage to body organs (lung, liver, kidney, heart, and brain tissue) which increases morbidity and mortality rates. Lung tissue is an easily affected target organ, and damage from Ischemia-reperfusion injury can cause acute lung injury and acute respiratory distress syndrome. These conditions damage the endothelium and epithelium of the lung parenchyma resulting in edema and impaired gas diffusion with a very high mortality rate of around 25-40%. The combination therapy of Pentoxifylline and Vitamin C in reducing the effect of Ischemia-reperfusion injury on lung tissues and have shown a protective effect of lung tissue damage due to ischemia-reperfusion injury in lower limbs.

Management of Acute Limb Ischaemia Due to COVID-19 Induced Arterial Thrombosis: A Multi-Centre Indian Experience

Objective: To determine the outcomes following various surgical and medical treatments of Coronavirus disease 2019 (COVID-19) induced acute limb ischaemia.Methods: A retrospective study of patients presenting with COVID induced arterial ischaemia in three hospitals from Southern India during the months of May 2020 to August 2021 was undertaken. These patients were managed by either thrombectomy, primary bypass, thrombolysis, anticoagulation or primary amputation based on the stage of ischaemia and the severity of COVID.Results: A total of 67 limbs in 59 patients were analysed. The average time to intervention was 15 days. Upper limb involvement was seen in 16 and lower limb in 51 limbs. Of the 67 limbs, 39 (58.2%) were treated by open surgical revascularisation, 5 (7.4%) by catheter directed lysis, 17 (25.3%) were managed conservatively and 6 (8.9%) underwent primary amputation. Successful revascularisation could be carried out in 88.6% of patients. A limb salvage rate of 80.6% was achieved in these patients with a re-intervention rate of 13.6%. Major amputation rate was 14.92% and mortality was 13.56%.Conclusion: Limb ischaemia after COVID can be safely managed by open thrombectomy or bypass. Similar rates of limb salvage as in non-COVID acute limb ischaemia can be obtained.

The complexity of perioperative management of acute limb ischemia in elderly with multiple comorbidities and underlying diseases: A case report

Background: Aging process commonly associated with multiple comorbidities such as metabolic disorders, vascular, visual, gait, balance and psycho-social problems. Atherosclerosis is one of comorbidities that could occur as a pre-existing condition in elderly with peripheral artery disease (PAD). Elderly patients associated with complex and multi-factorial medical conditions need to be addressed in a comprehensive approach. Here we report the complexity of perioperative management of an elderly with acute limb ischemia in elderly with multiple comorbidities and underlying diseases.
 Case Presentation: An elderly woman, 77-year-old, was referred to emergency room due to decreased level of consciousness. There were complaints of loss appetite, inactivity, bedridden, pain, paresthesia and muscle weakness in the right lower limb. There was history of chronic hypertension and dyspepsia. Since there was a sign of right lower limb acute limb ischemia, the patient was discussed with the multi-discipline team, planned for primary amputation, and received systemic anticoagulant treatment. Due to multiple comorbidities and underlying diseases, the patient died prior to amputation surgery.
 Conclusion: Surgery is not contraindication to elderly; however, from this case it shed light the needs of multi-discipline approach to decide the best treatment options for patient’s needs. Utilizing a Comprehensive Geriatric Assessment (CGA) could be an alternative to non-invasive, simple, and effective approach available in any healthcare setting.

Diagnosis and Management of Acute Limb Ischemia

Introduction: Acute limb ischemia is considered as a life threatening disease .After twelve hours of ischemia, chances of saving the ischemic limb are lower (78%), with higher mortality (31%) as well. Methods: A total of 54 patients who underwent surgery for acute non traumatic limb ischemia between January 2013 and December 2020 were retrospectively reviewed. Results: We included 30 women and 24 men; median age was 69 years. Twenty patients (37%) were presented with upper limb ischemia, where as 34 patients (63%) with lower limb ischemia. Mean delay between the onset of symptoms and hospital admission of upper limb ischemia was 22 hours, 35% of Patients were diagnosed at the stage IIA of Rutherford classification, while 65% were diagnosed at the stage of II B. Lower limb ischemia patients were admitted after 28.5 hours, 64.8% of patients were diagnosed at the stage of II A of Rutherford, while 32.3% were diagnosed at the stage of II B of Rutherford. Revascularization of all ischemic upper limbs (100%) and the majority of ischemic lower limbs (94.1%) were carried out through endovascular thromboembolectomy with Fogarty ballooncathete. Meanlength of hospitalstaywas 8.3 days for upper limb ischemia cases ; while lower limb ischemia patients required 9.2 days of mean hospitalstay. We report a total of 4 deaths (7.4%). Conclusion: Acute limb ischemia remains a challenging entity for clinicians with significant risk of patient limbloss and mortality. Prompt diagnosis, anticoagulation, and timely revascularization are crucial to minimize the risk of limbloss.

Presentation and Management of Acute Limb Ischemia Following Lower Extremity Revascularization: Insights from the VOYAGER PAD Trial

Acute limb ischemia (ALI) is a major adverse limb event associated with high morbidity and mortality. Despite the severity of this outcome, there are few large datasets including adjudicated ALI outcomes that have elucidated treatment approaches and outcomes after ALI. Data describing the presentation, initial care, and subsequent antithrombotic prophylaxis in patients with ALI after lower extremity revascularization (LER) for symptomatic peripheral artery disease (PAD) would provide valuable insights. The VOYAGER PAD trial randomized patients with PAD after LER to rivaroxaban 2.5 mg twice daily plus aspirin or matching placebo plus aspirin and followed for a median of 28 months. Patients were randomized across 34 countries. Site-reported ALI was independently adjudicated by a clinical events committee. Each event was categorized by trained vascular specialists for etiology, relationship to index or subsequent LER, inpatient therapy, discharge treatment strategy, and hospital outcomes. Of the 6564 randomized patients, 390 (5.9%) had 516 total ALI events during follow-up. ALI etiology was in situ thrombosis in 97.8%, embolism from nonextremity source in 1.9%, and undetermined in 0.3%. Anatomic location was prior bypass in 49%, arterial stent in 31%, and native arterial segment (of these, three-quarters were prior endarterectomy, atherectomy, or angioplasty sites) in 18%. Fifty-eight percent of ALI were related to the index LER, 36% were related to a prior or subsequent nonindex LER, and 6% were at a non-LER arterial site. The initial intervention strategy (Fig 1) was thrombectomy in 41% (three-quarters were open and 71% required an additional open/endovascular revascularization or major amputation at some point in hospitalization). Thrombolysis was the initial strategy in 19% and 76% of these underwent an additional open/endovascular revascularization or major amputation during the hospitalization. Median hospital stay was 6 days. Fasciotomy occurred in 6% of patients, severe complications (ventilator, shock, or dialysis) occurred in 4%, major amputation in 13%, and mortality in 2.3%. Discharge antithrombotic background therapy (excluding study drug) was variable (Fig 2). ALI in the post-LER setting is frequent and largely in-situ thrombosis at the site of prior LER. Presentation with ALI is associated with prolonged hospitalization, the need for procedures and/or amputation and high inpatient mortality. Initial therapeutic approaches in patients presenting with ALI are varied as are approaches to thromboprophylaxis. These observations highlight the need for future research investigating the optimal approach to treating patients with ALI and therapeutic strategies to prevent recurrent complications.Fig 2Discharge Anti-Thrombotic Regimen.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Update of the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia in Light of the COVID-19 Pandemic, Based on a Scoping Review of the Literature

Update of the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia in Light of the COVID-19 Pandemic, Based on a Scoping Review of the Literature

Percutaneous thrombectomy or ultrasound-accelerated thrombolysis for initial management of acute limb ischaemia.

Acute limb ischaemia (ALI), the sudden and significant reduction of blood flow to the limb,is considered a vascular emergency. In the general population, the incidence is estimated as 14 per 100,000. Prognosis depends on the time it takes to diagnose the condition and begin appropriate treatment. Standard initial interventional treatments include conventional open surgery and endovascular interventions such as catheter-directed thrombolysis (CDT). Percutaneous interventions, such as percutaneous thrombectomy (PT, including mechanical thrombectomy or pharmomechanical thrombectomy) and ultrasound-accelerated thrombolysis (USAT), are also performed as alternative endovascular techniques. The proposed advantages of PT and USAT include reduced time to revascularisation and when combined with catheter-directed thrombolysis, a reduction in dose of thrombolytic agents and infusion time. The benefits of PT or USAT versus open surgery or thrombolysis alone are still uncertain. In this review, we compared PT or USAT against standard treatment for ALI, in an attempt to determine if any technique is comparatively safer and more effective. To assess the safety and effectiveness of percutaneous thrombectomy or ultrasound-accelerated thrombolysis for the initial management of acute limb ischaemia in adults. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, the World Health Organization (WHO) International Clinical Trials Registry Platform, and ClinicalTrials.gov to 3 March 2021. We searched reference lists of relevant studies and papers. We included randomised controlled trials (RCTs) that compared PT (any modality, including mechanical thrombectomy (aspiration, rheolysis, rotation) or pharmomechanical thrombectomy) or USAT with open surgery, thrombolysis alone, no treatment, or another PT modality for the treatment of ALI. Two review authors independently selected the studies, assessed risk of bias, extracted data, performed data analysis, and assessed the certainty of evidence according to GRADE. Outcomes of interest were primary patency, amputation rate, major bleeding, clinical success, secondary patency, and adverse effects. We included one RCT in this review. This study had a total of 60 participants and compared USAT with standard treatment (CDT). The study included 32 participants in the CDT group and 28 participants in the USAT group. We found no evidence of a difference between USAT and CDT alone for the following evaluated outcomes: amputation rate (risk ratio (RR) 1.14, 95% confidence interval (CI) 0.17 to 7.59); major bleeding (RR 1.71, 95% CI 0.31 to 9.53); clinical success (RR 1.00, 95% CI 0.94 to 1.07); and adverse effects (RR 5.69, 95% CI 0.28 to 113.72). We rated the certainty of the evidence as very low for these outcomes. We downgraded the certainty of the evidence for amputation rate, major bleeding, clinical success, and adverse effects by two levels due to serious limitations in the design (there was a high risk of bias in critical domains) and by two further levels due to imprecision (a small number of participants and only one study included). The study authors reported 30-day patency, but did not report primary and secondary patency separately. The patency rate in the successfully lysed participants was 71% (15/21) in the USAT group and 82% (22/27)in the CDT group. The study authorsdid not directly report secondary patency, which is patency after secondary procedures, but they did report on secondary procedures. Secondary procedures were subdivided into embolectomy and bypass grafting. Embolectomy was performed on 14% (4/28) of participants in the USAT group versus 3% (1/32) of participants in the CDT group. Bypass grafting was performed on 4% (1/28) of participants in the USAT group versus 0% in the CDT group. As we did not have access to the specific participant data, it was not possible to assess these outcomes further. We did not identify studies comparing the other planned interventions. There is insufficient evidence to assess the safety and effectiveness of USAT versus CDT alone for ALI for our evaluated outcomes: amputation rate, major bleeding, clinical success, and adverse effects. Primary and secondary patency were not reported separately. There was no RCT evidence for PT. Limitations of this systematic review derive from the single included study, small sample size, short clinical follow-up period, and high risk of bias in critical domains. For this reason, the applicability of the results is limited. There is a need for high-quality studies to compare PT or USAT against open surgery, thrombolysis alone, no treatment, or other PT modalities for ALI. Future trials should assess outcomes, such as primary patency, amputation rate, major bleeding, clinical success, secondary patency, and adverse effects.

Infusion techniques for peripheral arterial thrombolysis.

Infusion techniques for peripheral arterial thrombolysis.

Young Age Is Associated With Poor Short-Term Limb Outcomes After Acute Limb Ischemia

The objective of the present study was to evaluate the contemporary trends in the management of acute limb ischemia (ALI) and to outline the factors that might contribute to poor outcomes in young patients.

Acute Limb Ischaemia in the COVID-19 Era: a Clinical and Organisational Challenge

In February 2020, the European Society for Vascular Surgery (ESVS) Clinical Practice Guidelines on the Management of Acute Limb Ischaemia (ALI) were published in an issue of this Journal.1 They were the first ALI guidelines ever published and offered guidance on therapeutic decision making for this complex condition. Shortly after the release of the guidelines, the COVID-19 pandemic took the world by surprise, challenging health systems across the globe and transforming the way we practice medicine and surgery.

The Protective Effect of Vitamin E for Reducing Intra-Hospital Mortality in Acute Limb Ischemia Patients

Background
 Management of acute limb ischemia (ALI) is still a huge challenge. Current advances of endovascular therapeutic approach in management of ALI have decreased the overall amputation rate, nevertheless, mortality rate remains high which may be caused by metabolic consequences of reperfusion injury.
 Aim
 To understand the role of vitamin E to intra-hospital and 30-day mortality among acute limb ischemia patients.
 Methods
 This retrospective cohort study included all patients with ALI between 2015 to 2018. Vitamin E 2x400 mg orally for seven days was given based on physician preference after ALI diagnosis was confirmed. Data were collected from Vascular Registries of National Cardiovascular Center Harapan Kita (NCCHK), Jakarta, Indonesia. Univariate analysis and logistic regression models were used to explore factors that contribute to intra-hospital and 30-day mortality.
 Results 
 A total of 160 patients with ALI involving 192 limbs were admitted to our hospital. Mostly were male (63.1%) and mean age were 56±13 years old. Majority of the patients had unilateral lesion (80%), and were diagnosed with Rutherford stage IIA (36.3%), followed by stage IIB (33.8%), stage I (20%), and stage III (10%) respectively. Intra-hospital and 30-day mortality were 28.1% and 36.9%, respectively. Low treatment of vitamin E increased intra-hospital mortality (HR 5,6 95%CI 1.7-18.3), however, it did not affect 30-day mortality. Other factors including IABP insertion, arrhythmia, bleeding requiring transfusion and acute renal failure were associated with higher intra-hospital and 30-day mortality. In addition, menopause (HR 3.2; CI 1.16-8.85) was also a predictor of 30-day mortality.
 Conclusion
 Vitamin E administration reduced intra-hospital mortality but not on 30-day mortality in acute limb ischemia patients.
 Keywords: Acute Limb Ischemia, vitamin E, mortality, reperfusion injury

ACUTE LIMB ISCHEMIA: AN UPDATE ON DIAGNOSIS AND MANAGEMENT

Acute Ischemic Limb (ALI) is a condition in which there is a sudden decrease in perfusion of stool caused by thrombus and embolism. The thrombus in question is derived from the development of arterial disease, aortic dissection, thrombus graft, aneurysm, hypercoagulability, iatrogenic and other.This review presents an update on the diagnosis and management of acute limb ischemia (ALI), a severe condition associated with high mortality and amputation rates. A comprehensive spectrum of ALI etiology is presented, with highlights on embolism and in situ thrombosis. The steps for emergency diagnosis are described, emphasizing the role of clinical data and imaging, mainly duplex ultrasound, CT angiography and digital substraction angiography. The different therapeutic techniques are presented, ranging from pharmacological (thrombolysis) to interventional (thromboaspiration, mechanical thrombectomy, and stent implantation) techniques to established surgical revascularization (Fogarty thrombembolectomy, by-pass, endarterectomy, patch angioplasty or combinations) and minor or major amputation of necessity. Postprocedural management, reperfusion injury, compartment syndrome and long-term treatment are also updated

Neonatal acute limb ischemia

Abstract Acute limb ischemia is a rare disorder in the perinatal period. The etiology and management of acute limb ischemia is not well described. We report 4 cases of acute limb ischemia in the neonatal period. Observations We present the cases of four premature neonates aged between 6 and 15 days. The mothers of one of the neonates had a history of gestational diabetes. Three neonates were born by eutocic vaginal delivery and one, by cesarean section. Reasons for hospitalization of the neonates included infections (3 cases), hyaline membrane disease (2 cases) and congenital malaria (1 case).The neonates presented with cyanosis localized in the fingers (1 case), cyanosis on the fingers extending to the forearm (2 cases) and cyanosis localized in the toe (1 case). All patients had a peripheral intravenous catheter implanted in the affected limb. In three cases, there was an infectious syndrome and in one case, hemostasis was impaired. Doppler ultrasound of the blood vessels in the affected limb revealed arterial thrombosis in 2cases. Management involved antibiotics, heparin therapy and fasciotomy. During hospitalization, 1 patient had spontaneous distal phalanx amputation, 1 required surgery for forearm segmental gangrene and 2 died. Conclusion Neonatal acute limb ischemia is rare but can be fatal due to functional and vital repercussions. Treatment outcomes depend on early diagnosis, etiology and treatment.

Outcome of percutaneous transluminal angioplasty for subacute lower limb ischemia

Context Management of acute limb ischemia ( Aim The aim of this study was to evaluate the clinical and hemodynamic outcome of percutaneous transluminal angioplasty for subacute lower limb ischemia. Settings and design A total of 22 limbs that presented with subacute leg ischemia admitted to Alexandria Main University Hospital have been studied prospectively. All patients had femoro-popliteal occlusions shown by multislice computed tomographic angiography and severe leg ischemic pain +/− crippling claudication. Patients with acute leg ischemia or extensive foot necrosis necessitating amputation were excluded from the study. Patients and methods All patients were subjected to ankle-brachial index (ABI) measurement, color duplex ultrasound (CDU) scan, and multislice computed tomographic angiography before intervention. Percutaneous transluminal angioplasty (balloon angioplasty +/− stent deployment) was performed for all participants. Clinical follow-up with ABI measurement was done at 1-, 3-, and 6-month intervals. CDU after 6 months for patency and restenosis was performed. Statistical analysis Statistical Package for the Social Sciences, version 15.0 was used. Values were compared with a paired samples t test. P values less than 0.05 were considered significant. Results Mean follow-up period was 6.2 months. The mean (±SD) ABI before and at 1-, 3-, and 6-month interval was 0.4 (±0.2), 0.53 (±0.11), 0.62 (±0.12), and 0.86 (±0.16), respectively, with P value less than 0.0001. Limb salvage rate for those patients who had constant ischemic pain and had primary technical success was 89%. As for those patients who had severe claudication, at 6-month follow-up, they had no complaint. Primary patency rate by CDU was 95%. Conclusions Balloon angioplasty is a safe and effective tool for management of subacute leg ischemia. It avoids high surgical risks and carries promising patency and limb salvage rates.

Outcome of catheter directed thrombolysis for popliteal or infrapopliteal acute arterial occlusion.

Management of acute limb ischemia (ALI) due to occlusions in popliteal and infrapopliteal arteries remains a challenge. Open surgical methods and even the novel percutaneous mechanical thrombectomy devices have not shown satisfactory results in these small arteries. The aim of this prospective study was to assess the safety and efficacy of catheter-directed thrombolysis (CDT) in this type of ALI with distal occlusion. Between April 2017 and June 2019, 22 patients with ALI secondary to popliteal or infrapopliteal occlusion were enrolled in the study. Patients with thrombosis, embolism, and thrombosed bypass graft were included; all belong to category I or IIa of Rutherford's classification. Technical success, limb salvage, complications, and mortality were evaluated at short- and long-term follow-up. Technical success was achieved in 81.8%, while 36.4% of patients needed additional balloon angioplasty, major amputation in 13.6%, minor bleeding in 18.2%, andno major hemorrhage. Limb salvage at 30days and 1year was 86.4% and 72.7%, respectively. At 1year, primary patency was 63.6% and mortality was 9.1%. Catheter directed thrombolysis is a safe and highly effective treatment modality for popliteal or infrapopliteal acute limb ischemia unless contraindicated.

Results of the Surgical Management of Acute Limb Ischemia in the Nonagenarians

The aging of the population leads us to treat older patients, in particular presenting with acute limb ischemia (ALI). However, there has been little evaluation of this pathology in the nonagenarians. The objectives of this work are thus to evaluate the 1-month and 1-year mortality of the nonagenarians treated for ALI, which made possible to determine the 1-year survival and to highlight the factors influencing the mortality. This is a monocentric retrospective study including all the patients aged 90years old or more surgically treated for ALI between January 2012 and December 2016. In all the patients, we recorded the 1-month mortality and the 1-year survival and the demographic, clinical, and paraclinical data. We operated 83 nonagenarians, with a majority of women (59, 71.1%), using general anesthesia in 20 patients (16.6%), including 10 cases of upper limb acute ischemia (12.0%). The overall mortality rate at 1 month was 22.9%, and the 1-year survival rate was 43.4%. Major amputation rate was 9.6% at 1 year. The survival of the patients operated for upper or lower limb ischemia was similar (P=0.82). Univariate analysis showed that the 1-year survival was lower in patients having a history of cerebrovascular problems (P=0.0003), heart failure (P=0.0027), dementia (P=0.0452), or in patients that were institutionalized (P=0.0125), invalid (P=0.0001), or presented with a complete acute ischemia (P=0.0002). In multivariate analysis, 3 risk factors remained statistically significant: a previous history of cerebrovascular accident (hazard ratio [HR]=3.05 [1.54-6.02]; P=0.0014), cardiac failure (HR=2.21 [1.23-3.97]; P=0.0083), and complete ALI (HR=3.07 [1.64-5.75]; P=0.0005). Our study showed that a history of cerebrovascular accident, cardiac failure, or complete ALI is a poor prognostic factor for the 1-year survival of nonagenarians dealt operated for ALI. These elements should be taken into account when deciding either to operate or not in this precise context.