Occlusion Of External Iliac Artery Research Articles

The Clinical Impact of Access Site Selection for Successful Thrombolysis and Intervention in Acute Critical Lower Limb Ischaemia (RAD-ALI Registry).

Background: Acute limb ischaemia (ALI) is of great clinical importance due to its consequent serious complications and high comorbidity and mortality rates. The purpose of this study was to compare the acute success and complication rates of CDT performed via transradial, transbrachial, and transfemoral access sites in patients with acute lower limb vascular occlusion and to investigate the 1-year outcomes of CDT and MT for ALI. Methods: Between 2008 and 2019, 84 consecutive patients with ALI were treated with CDT in a large community hospital. Data were collected and retrospectively analysed. The primary ("safety") endpoints encompassed major adverse events (MAEs), major adverse limb events (MALEs), and the occurrence of complications related to the access site. Secondary ("efficacy") endpoints included both technical and clinical achievements, treatment success, fluoroscopy time, radiation dose, procedure time, and the crossover rate to an alternative puncture site. Results: CDT was started with radial (n = 17), brachial (n = 9), or femoral (n = 58) access. CDT was technically successful in 74/84 patients (88%), but additional MT and angioplasty and/or stent implantation was necessary in 17 (20.2%) and 45 cases (53.6%), respectively. Clinical success was achieved in 74/84 cases (88%). The mortality rate at 1 year was 14.3%. The cumulative incidence of MAEs and MALEs at 12 months was 50% and 40.5%, respectively. After conducting multivariate analysis, history of Rutherford stage IIB (hazard ratio [HR], 3.64; 95% confidence interval [CI], 1.58-8.41; p = 0.0025), occlusion of the external iliac artery (HR, 27.52; 95% CI, 2.83-267.33; p = 0.0043), being a case of clinically unsuccessful thrombolysis (HR, 7.72; 95% CI, 2.48-23.10; p = 0.0004), and the presence of diabetes mellitus (HR, 2.18; 95% CI, 1.01-4.71; p = 0.047) were independent predictors of a high MAE mortality rate at 12 months. For MALEs, statistically significant differences were detected with the variables history of Rutherford stage IIB (HR, 4.30; 95% CI, 1.99-9.31; p = 0.0002) and external iliac artery occlusion (HR, 31.27; 95% CI, 3.47-282.23; p = 0.0022). Conclusions: Based on the short-term results of CDT, acute limb ischaemia can be successfully, safely, and effectively treated with catheter-directed thrombolytic therapy with radial, brachial, or femoral access. However, radial access is associated with fewer access site complications. A history of Rutherford stage IIB, occlusion of external iliac artery, unsuccessful thrombolysis, and the presence of diabetes mellitus were independently associated with an increased risk of MAEs. A history of Rutherford stage IIB and external iliac artery occlusion are independent predictors of MALEs.

Mitochondrial and Microvascular Impairments in a Novel Swine Model of Peripheral Artery Disease

Introduction: Impaired skeletal muscle mitochondria and microvascular function have been reported in human peripheral artery disease (PAD). However, no large animal models of PAD have mimicked these impairments. Purpose: The purpose of this study was to examine the skeletal muscle microvasculature and mitochondria in a novel swine model of PAD. Hypothesis: We hypothesized that hindlimb ischemia leads to dysfunction of skeletal muscle microvessels and mitochondria. Methods: Ossabaw swine (n=5) with metabolic syndrome underwent endovascular coil occlusion of the right external iliac artery to generate hindlimb ischemia (ISC). The left leg served as a non-ischemic control (CON). After 4-weeks, biopsies were collected from both legs (lateral gastrocnemius). Skeletal muscle arterioles were assessed using video microscopy. Microvascular vasodilatory function was assessed in response to flow (Shear stress), acetylcholine (ACh), and sodium nitroprusside (SNP). Skeletal muscle mitochondrial function was assessed using high-resolution respirometry. Substrates were administered as follows: malate (M) & glutamate (G), adenosine diphosphate (ADP), succinate (S), oligomycin, and ascorbate (Asc) & N,N,N,N-tetramethyl-phenylenediamine (TMPD). Complex I state 2 (CI-S2) was assessed as M+G, complex I state 3 (CI-S3) was assessed as (M+G+ADP)-(M+G), complex II state 3 (CII-S3) was assessed as (M+G+ADP+S)-(M+G+ADP), complex I&II state 3 (CI&II S3) was assessed as (M+G+ADP+S)-(M+G), state 4 (S4) was assessed after oligomycin, and complex IV (CIV) respiration was assessed after Asc+TMPD. The respiratory control ratio (RCR) was calculated as CI&II-S3/S4. Results: Vasodilation in response to flow was reduced in ISC vs. CON (Δ-13.1±13.7%, p=0.01). but not in response to ACh (Δ-6.2±17.7%, p=0.23) or SNP (Δ1.7±11.0%, p=0.53). Additionally, CI-S2 (Δ-0.3±3.7 pmolO2·s−1·mg−1, p=0.65), S4 (Δ-1.7±4.4 pmolO2·s−1·mg−1, p=0.14), and CIV (Δ-2.8±20.9 pmolO2·s−1·mg−1, p=0.65) were not different between ISC and CON. However, CI-S3 (Δ-4.7±5.0 pmolO2·s−1·mg−1, p<0.01), CII-S3 (Δ-3.5±5.0 pmolO2·s−1·mg−1, p=0.02), CI&II-S3 (Δ-8.5±8.7 pmolO2·s−1·mg−1, p<0.01), and RCR (Δ-0.8±1.3 pmolO2·s−1·mg−1, p=0.04) were all reduced in ISC vs. CON. Conclusions: We found that skeletal muscle microvessels and mitochondria were impaired in our swine model. Based on the present findings, we conclude that our novel porcine model closely replicates the pathophysiology PAD, making it a promising large animal model for studying human PAD. This research was supported by the National Institutes of Health (R01HD106911, R01AG062198, R01AG0778031) and the Great Plains IdeA-CTR (U54 GM115458). This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

External iliac artery injury with posterior pelvic ring injury in Korea: a report of two cases

Pelvic ring injuries associated with external iliac artery injuries are rare and may be life-threatening condition. The most important factors in the managements are the immediate bleeding control and restoration of distal blood flow. We report two cases of pelvic ring injuries with external artery injuries. One case was occlusion of external iliac artery with concomitant rupture of internal iliac artery. The other case was ruptured external iliac artery. Every surgeon must understand the possibility of hidden lesions—for example, arterial rupture and thrombus—and should consider the need for embolization or thrombectomy when treating this type of injury.

Abstract 12906: Exercise Training Protects Against Ischemic Muscle Damage in a Large-Animal Model of Peripheral Artery Disease

Peripheral artery disease (PAD) causes an ischemic myopathy in the lower extremity muscles, which contributes to patient functional disability. Although structured exercise therapy is a leading therapeutic to improve ambulatory function, the impact of exercise on PAD myopathy is unclear. Using our porcine model of PAD, we sought to elucidate the effect of hindlimb ischemia on markers of 1) muscle damage (caspase 3, myogenic differentiation 1 (MyoD), and Forkhead box protein O1 (FOXO1)), 2) muscle protein turnover (autophagic flux and proteolytic activity), and 3) whether these indices were altered with exercise training. Methods: Seven Yorkshire swine were exposed to right hindlimb ischemia by endovascular external iliac artery occlusion. Following ischemia onset, the swine were divided into 2 training groups: supervised exercise trained (ET) (n=4) and sedentary controls (SED) (n=3). ET pigs followed an incremental treadmill protocol 3 times weekly for 4 weeks. SED pigs had standard ambulation. The tibialis anterior from ischemic and non-ischemic limbs was excised after animal termination. Markers of muscle damage and proteolytic activity were assessed via RT-PCR and enzymatic activity kits, respectively. The ratio of intramuscular microtubule-associated protein light chain 3 (LC3)-II:LC3-I, as well as sequestosome (p62), and mitofusion2 (MFN2) content from immunoblots were used to monitor autophagic flux. Results: Gene expression of intramuscular damage was significantly higher in SED ischemic muscle compared to ET muscle (caspase 3 (SED: 5.59±1.5; ET: 1.67±1.5), MyoD (SED: 4.55±1.2; ET: 1.24±1.5) and FOXO1 (SED: 1.74±0.5; ET: 1.07±1.1), p<0.0001). Moreover, ischemic muscle from ET pigs showed no alteration in markers of muscle damage when compared to the SED and ET non-ischemic conditions (p>0.05). Although proteolytic activity was unaltered (p>0.05), autophagic flux tended to be increased in ET ischemic muscle (LC3-II:LC3-I ratio (ET: 0.21±0.1; SED: 0.10±0.1 AU, p=0.099), p62 (ET: 15.80±5.1; SED: 7.75±2.8 AU, p=0.068) and MFN2 (ET: 42.72±15.9; SED: 16.82±11.3 AU, p=0.214). Conclusions: These data suggest exercise therapy is protective against ischemic muscle damage and may improve muscle quality via accelerating autophagic flux.

Hybrid Revascularization for Extensive Iliofemoral Occlusive Disease

Total occlusion of the iliac-femoral tract can cause a variety of life-limiting symptoms ranging from mild claudication to chronic limb-threatening ischemia. Efforts should be made to revascularize the symptomatic ischemic limb. Currently there are different options in the vascular surgeon's armamentarium to achieve this. The aim of the study was to verify the feasibility and outcomes of inflow hybrid revascularizations combining femoral endarterectomy and recanalization of iliac atherosclerotic occlusion. A retrospective review was conducted of all hybrid revascularizations involving femoral endarterectomy and endovascular treatment of iliac occlusion. The operations were performed in Helsinki University Hospital between January 2013 and December 2018. First, information about patients' baseline characteristics, indications and details of surgery and technical/hemodynamic success, and complications and mortality were obtained from the vascular registry and patients records. Secondarily, a prospective assessment of mid-term patency was performed through follow-up in November 2019. Immediate technical success, 30-day mortality, complications, and patency were considered major outcomes. Hemodynamic improvement, amputation rate, and overall mortality were also assessed. One hundred sixty three iliofemoral occlusions were performed on 147 patients during the period studied. Six patients (3.6%) had infrarenal aortic occlusion, 86 (52.7%) had common iliac, and 128 (78.5%) had external iliac artery occlusion. Technical success rate was 88.3% (n=144 occlusions recanalized). Primary technical success was somewhat lower in lesions ≥ 90mm (87.1%) compared to lesions shorter than 90mm (95.7%; χ2P=0.06). Iliac stent was deployed in 141 (94.6%) cases, 51 (34.3%) of which were covered stents. Significant residual stenosis remained in 1.2% of cases. Median operative time was 4hr 34min (interquartile range 2 hr 43min) and median estimated blood loss was 743mL (interquartile range 500mL). Five patients (3.0%) developed a deep groin infection and 12 (8.1%) suffered any major cardiovascular event or stroke perioperatively. Primary patency at 30day, 6months, 1 year, and 2years was 98.7%, 98.1%, 96.6%, and 93.7%, respectively. Hemodynamic success was documented in 107 patients (73%). By the end of the follow-up, 7 iliofemoral tracts (11.1%) reoccluded, 2 limbs (1.2%) required amputation, and 50 patients (3.0%) died. Good immediate success rate and mid-term patency can be achieved by hybrid revascularization of iliofemoral occlusions. Careful patient selection is mandatory because this population often suffers from universal atherosclerosis. The involvement of the aorta represents a significant determinant of worse long-term patency, although it did not preclude technical success.

Acute embolic mesenteric ischemia treated by complex endovascular stent-based angioplasty

Abstract Acute mesenteric ischemia is a life-threatening disease that can be managed by surgery or endovascular therapy. Endovascular therapy shows great efficacy and good clinical outcomes even in technically demanding interventions, and it can become an alternative to surgery. After the revascularisation of mesenteric arteries, we should take into account the risk of reperfusion injury with systemic inflammatory response syndrome and worse clinical outcomes. We present a case of acute embolic mesenteric ischemia associated with acute left external iliac artery occlusion due to poorly anticoagulated atrial fibrillation, treated by a complex multiple stent-based angioplasty.

Effects Of Exercise Training On Mitochondrial Function In A Large-animal Model Of Peripheral Artery Disease

PURPOSE: Our group has developed an endovascular porcine model of ischemic myopathy from peripheral artery disease (PAD). Herein, we tested the hypothesis that mitochondrial dysfunction and oxidative stress are attenuated by exercise training in this model. METHODS: Seven Yorkshire swine were exposed to acute right hindlimb ischemia (HLI) by endovascular external iliac artery occlusion. The swine were randomly separated into two groups: exercise trained (ET) (n = 4) and sedentary control (SED) (n = 3). Exercise training consisted of a structured exercise therapy program on a treadmill (GoPet USA- Model PR730) three days per week, starting 1 week prior to HLI induction and continuing for four weeks after HLI. Speed was increased weekly as tolerated by 1 km/h up to 3.5 km/h with a constant incline of 5%. Food lure was used to motivate animals to participate for as long as tolerated. The session was terminated when the animal reached severe fatigue preventing further exercise. SED animals were exposed to HLI with no ET (regular activity). After termination, mitochondrial respiration, and reactive oxygen species (ROS) production in permeabilized gastrocnemius fiber bundles were simultaneously measured by high-resolution respirometry. RESULTS: After training, the oxygen consumption rate was significantly increased in ischemic muscles, compared to SED during Complex III (CIII) respiration (ET: 14.92 ± 2.82; SED: 5.80 ± 2.26 pmols/sec/mg protein, p < 0.0001) and Complex IV (CIV) (ET: 39.16 ± 3.77; SED: 12.16 ± 1.40, p < 0.0001 pmols/sec/mg protein). In addition, ROS production was significantly attenuated after ET during CIII (ET: 3.21 ± 1.62; SED: 7.10 ± 0.94 pmols/s*ml, p < 0.0001) and CIV (ET: 4.14 ± 0.57; SED: 16.10 ± 0.44 pmols/s*ml, p < 0.0001). CONCLUSION: These data suggest that exercise therapy, which has established efficacy in PAD, is also effective in this new model. Thus, this model may be useful for testing therapeutics targeting the pathophysiological mechanisms of mitochondrial dysfunction and oxidative stress in PAD.

Long-term outcomes of endovascular treatment for aortic pseudoaneurysm in patients with Behçet's disease.

Behçet's disease (BD) is a multisystem inflammatory disorder with unknown etiology, and its aneurysmal lesions are associated with high mortality due to the high risk of rupture. This study intended to further explore the long-term safety and efficacy of endovascular therapy for BD-related aortic pseudoaneurysm (BAP). From January 2009 to May 2021, 17 BAP patients who underwent endovascular repair were retrospectively identified and enrolled. Adequate immunosuppressive treatment was instituted before and after endovascular treatment unless emergency surgery was required. The patients were followed up at 3, 6, and 12 months and yearly after the primary endovascular intervention by computed tomography angiography (CTA) examination. Nineteen BAPs were identified among 17 patients. BAPs located at the aortic arch were found in three patients (17.6%), descending thoracic aorta in 5 (29.4%), and abdominal aorta in 10 (58.8%; suprarenal abdominal aorta in 2 [11.8%], and infrarenal abdominal aorta in 8 [47.1%]). The mean ESR during admission was 56.5 ± 24.9mm/h (range = 30.0-120.0mm/h), which fell to 22.7 ± 18.4mm/h (range = 2.0-74.0mm/h) before the endovascular intervention (p < 0.001). The rate of favorable immunosuppressive control before intervention is 76.5% (13/17). Technical success was achieved in all patients. Median follow-up time was 57.0months (interquartile range [IQR] = 21.3-67.3months). Pseudoaneurysm recurrence was observed in four patients, type I endoleak in one, pseudoaneurysms sac dilation in one, and external iliac artery occlusion in 1. Two patients died of pseudoaneurysm rupture. Five-year accumulated overall rate, recurrence-free rate, and reintervention-free survival rate of BAP patients were 92.8%, 75.4%, and 71.8%, respectively. Endovascular treatment in BAP patients seemed to be associated with long-term safety and efficacy with a 5-year overall survival rate of 92.8%. Adequate immunosuppressive treatment was essential for BAP patients to prevent aortic pseudoaneurysm recurrence and improve the prognosis.

The Effect of Retrograde External Iliac Artery Runoff on Aortofemoral Bypass Limb Patency

Superficial femoral artery and profunda patency has been shown to affect aortofemoral bypass (AFB) limb patency. However, the effect of retrograde flow through the external iliac artery (EIA) is unknown and is the subject of this analysis. Institutional AFB data from 2000 to 2017 were gathered, excluding that where Superficial femoral artery /EIA patency could not be determined. The cohort was divided into limbs with and without EIA occlusion; primary outcome was limb-based primary patency. Kaplan-Meier estimated patency; cox proportional-hazards model evaluated EIA patency while controlling for other factors. Over the study period, there were AFB 557 limbs in 281 patients. Of the 435 AFB limbs in 220 patients that met inclusion criteria and were included in the analysis, 162 had EIA occlusion and 273 had a patent EIA. Mean age was 69.6 ± 9.0. EIA occlusions were more common in male patients (59.9% vs. 44.6%; P=0.001), patients with CAD (43.8% vs. 34.1%; P=0.042), COPD (34.6% vs. 20.5%; P=0.001), and CHF (14.8% vs. 5.9%; P=0.002). Limbs with EIA occlusions more often underwent end-to-side proximal anastomosis (40.7% vs. 24.2%; P < 0.001) and simultaneous infrainguinal bypass (7.4% vs. 0.7%; P < 0.001). Median clinical follow-up was 4.4 years (IQR: 1.6-8.4). Five-year primary patency was 83.1% (95% CI: 74.5-90.0%) for EIA occlusion limbs and 85.9% (95% CI: 80.2-90.0%) with patent EIA limbs (P=0.96). While controlling for other factors, EIA stenosis or occlusion did not affect primary patency. For patients with a proximal occlusion (occluded aorta, occluded common iliac, or end-to-end proximal anastomosis) and occluded SFA (N=73), EIA occlusion had a HR of 1.92 for loss of patency, but this was not statistically significant. EIA patency did not influence primary patency in the overall cohort Further investigation on the topic in specific patient subgroups is warranted to determine the effect of EIA patency.

COMPLICATIONS AFTER PARTIAL, TOTAL OR EXTENDED SACRECTOMY: A CASE SERIES

ABSTRACT Objective The aim of this study was to conduct a survey of the different complications of partial, total or extended sacrectomy for the treatment of spinal tumors. Method This study is a descriptive analysis of medical records from a series of 18 patients who underwent sacrectomy between 2010 and 2019 at a tertiary center specializing in spinal tumor surgeries. The variables analyzed were sex, age, hospitalization time, oncologic diagnosis, posterior fixation pattern, rate of complications, and Frankel, ASA and ECOG scales. Results Of the 18 patients, 10 (55.5%) were male and 8 (44.5%) were female, and the mean age was 48 years. The mean hospitalization time was 23 days. Of the 18 patients, 8 (44.5%) contracted postoperative infections requiring surgery. Perioperative complications included liquoric fistula (22.25%), hemodynamic instability requiring vasoactive drugs in the immediate postoperative period (22.25%), wound dehiscence (11.1%), acute obstructive abdomen (11.1%), occlusion of the left external iliac artery (11.1%), immediate postoperative death due to acute myocardial infarction (11.1%), and intraoperative death due to hemodynamic instability (11.1%). Conclusions Partial, total or extended sacrectomy is a complex procedure with high morbidity and mortality, even in centers specializing in the treatment of spinal tumors. Level of evidence IV; case series study.

Outcomes of Hypogastric Coverage and Occlusion during Endovascular Treatment of Aortoiliac Occlusive Disease

The risk of hypogastric occlusion (HO) following bare-metal stent (BMS) coverage of the hypogastric origin during endovascular treatment of aortoiliac occlusive disease (AIOD) is unclear. This study sought to determine the rate and clinical significance of HO following BMS coverage during iliac stenting for complex AIOD. Consecutive patients undergoing elective iliac stenting for AIOD from 2010-2018 at Cleveland Clinic were reviewed. Patients with BMS coverage of a patent hypogastric origin were included. Rate of HO were determined by review of intraoperative angiography and follow up imaging. Predictors of HO were identified by univariable and multivariable logistic regression. Outcomes were compared between those who did and did not develop HO. There were 251 patients (338 limbs) with BMS coverage of the hypogastric origin during treatment of AIOD. Lesion severity was classified as TASC C/D in 249/338 (73.7%) of cases. Bilateral hypogastric coverage occurred in 93/251 (37.1%) patients. Hypogastric patency was 78.1% at 24-months following coverage. Recanalization of an ipsilateral external iliac artery (EIA) occlusion was predictive of HO (HR 3.12, 95% CI: 1.33, 7.34; P= 0.009). Increased luminal diameter of the hypogastric origin protected against HO (HR 0.64; 95% CI: 0.47, 0.88; P= 0.006). Perioperative outcomes were no different between patients with and without HO. There were no cases of gluteal necrosis, spinal cord ischemia, or pelvic organ ischemia. Four-year mortality and limb salvage were not affected by HO. HO was associated with decreased primary patency of ipsilateral iliac stents and increased risk of ipsilateral reintervention (HR 5.49; 95% CI: 1.82, 16.58; P= 0.002). HO is relatively infrequent following BMS coverage during treatment of AIOD. Luminal diameter of the hypogastric origin and ipsilateral EIA occlusion are associated with occlusion. HO is well tolerated in AIOD, though it is potentially associated with increased risk iliac stent occlusion and reintervention.

Performance of a novel temporary arterial shunt in a military-relevant controlled hemorrhage swine model.

In military trauma, temporary vascular shunts restore arterial continuity until delayed vascular reconstruction, often for a period of hours. A novel US Air Force-developed trauma-specific vascular injury shunt (TS-VIS) incorporates an accessible side port for intervention or monitoring, which may improve patency under adverse hemodynamic conditions. Our objective was to evaluate TS-VIS patency in the setting of volume-limited resuscitation from hemorrhagic shock. Female swine (70-90 kg) underwent 30% hemorrhage and occlusion of the left external iliac artery for 30 minutes. Animals were allocated to one of three groups (n = 5 per group) by left external iliac artery treatment: Sundt shunt (SUNDT), TS-VIS with arterial pressure monitoring (TS-VIS), or TS-VIS with heparin infusion (10 μ/kg per hour, TS-VISHep). Animals were resuscitated with up to 3 U of whole blood to maintain a mean arterial pressure (MAP) of >60 mm Hg and were monitored for 6 hours. Bilateral femoral arterial flow was continuously monitored with transonic flow probes, and shunt thrombosis was defined as the absence of flow for greater than 5 minutes. No intergroup differences in MAP or flow were observed at baseline or following hemorrhage. Animals were hypotensive at shunt placement (MAP, 35.5 ± 7.3 mm Hg); resuscitation raised MAP to >60 mm Hg by 26.5 ± 15.5 minutes. Shunt placement required 4.5 ± 1.8 minutes with no difference between groups. Four SUNDT thrombosed (three before 60 minutes). One SUNDT thrombosed at 240 minutes, and two TS-VIS and one TS-VISHep thrombosed between 230 and 282 minutes. Median patency was 21 minutes for SUNDT and 360 minutes for both TS-VIS groups (p = 0.04). While patent, all shunts maintained flow between 60% and 90% of contralateral. The TS-VIS demonstrated sustained patency superior to the Sundt under adverse hemodynamic conditions. No benefit was observed by the addition of localized heparin therapy over arterial pressure monitoring by the TS-VIS side port.

Traumatic Aortic Dissection Complicating Retrieval of an Embolised Atrial Septal Defect Closure Device

A 65 year old man presented with embolisation of an atrial septal defect closure device (Flex II, Occlutech, Helsingborg, Sweden) to the abdominal aorta. Endovascular attempts failed to recapture it within a 9Fr introducer. Despite significant friction in the aorta, the device was pulled to the right common iliac artery. Arteriography (A) and computed tomography scan (B) showed aortic dissection complicated by right external iliac artery occlusion. The device was removed surgically, and retroperitoneal iliofemoral bypass was performed. Pulling a non-covered device may cause vessel injuries; inability to recapture the device indicates the need for a larger sheath or open surgery.Image 1

The Effect of Retrograde External Iliac Artery Runoff on Aortofemoral Bypass Limb Patency

Superficial femoral artery (SFA) and profunda patency has been shown to affect aortofemoral bypass limb patency. However, the effect of retrograde flow through the external iliac artery (EIA) is unknown and is the subject of this analysis. Institutional aortofemoral bypass data from 2000 to 2017 were gathered, excluding those where SFA/EIA patency could not be determined. The cohort was divided into limbs with and without EIA occlusion; primary outcome was limb-based primary patency. Kaplan-Meier estimated patency, and a Cox proportional hazards model evaluated EIA patency while controlling for other factors. Over the study period, there were 557 limbs in 281 patients. Of the 435 limbs in 220 patients that met inclusion criteria and were included in the analysis, 162 had EIA occlusion and 273 had a patent EIA. Mean age was 69.6 ± 9.0 years. EIA occlusions were more common in male patients (59.9% vs 44.6%; P = .001), patients with coronary artery disease (43.8% vs 34.1%; P = .042), chronic obstructive pulmonary disease (34.6% vs 20.5%; P = .001), and congestive heart failure (14.8% vs 5.9%; P = .002). Limbs with EIA occlusions more often underwent end-to-side proximal anastomosis (40.7% vs 24.2%; P < .001) and simultaneous infrainguinal bypass (7.4% vs 0.7%; P < .001). Median follow-up was 4.6 years (interquartile range, 1.6-8.4 years). The 5-year primary patency was 83.1% (95% CI, 74.5%-90.0%) for EIA occlusion limbs and 85.9% (95% CI, 80.2%-90.0%) with patent EIA limbs (P = .96; Fig). While controlling for other factors, EIA occlusion did not affect primary patency (Table). For patients with a proximal occlusion (occluded aorta, occluded common iliac, or end-to-end proximal anastomosis) and occluded SFA (n = 73), EIA occlusion had a hazard ratio of 1.92 for loss of patency, but this was not statistically significant (P = .39) EIA patency did not influence primary patency in the overall cohort. EIA patency may contribute to graft failure in patients with an SFA occlusion, but this needs further study in a larger population.Table IMultivariable Cox model for primary limb-based patencyHR95% CIP valueEIA occlusion0.830.451.53.553 SFA occlusion2.121.114.03.022 Age (per each advancing year)0.970.941.00.037 Female sex1.700.923.14.091 History of VTE4.041.2013.63.024 Preoperative statin0.490.260.92.027 Simultaneous Infrainguinal bypass3.711.1312.21.031CI, Confidence interval; HR, hazard ratio; EIA, external iliac artery; SFA, superficial femoral artery; VTE, venous thrombotic event. Open table in a new tab

Acute External Iliac Artery Occlusion as an Uncommon Complication Encountered during Coronary Angiography.

A 40-year-old female patient presented to our cardiology department with typical angina of 1 month’s duration. The patient was on a combination of valsartan and hydrochlorothiazide for the treatment of hypertension. Electrocardiography showed a normal sinus rhythm with T-wave negativity in the anterior precordial leads. A cardiovascular stress test with the Bruce protocol revealed 2 mm horizontal ST-segment deviation in the inferior and lateral leads. Therefore, the patient was scheduled to undergo coronary angiography (CAG). Before CAG, she was anxious and stressed; hence, intravenous diazepam was administered. CAG, performed via the right femoral artery, demonstrated an insignificant muscular bridge in the mid-portion of the left anterior descending artery (Figure 1A). Twenty minutes after the procedure, the patient felt numbness in her right lower leg and had difficulties in her movements. On physical examination, there was no pulse in the right lower extremity. Because of the presence of the signs and symptoms of acute lower extremity ischemia, an urgent peripheral angiography via the left femoral artery was performed. It illustrated an acute occlusion in the external iliac artery (EIA) (Figure 1B and Video 1). Afterward, intravenous nitroglycerin and unfractionated heparin (5000 U) were given through the right diagnostic catheter. Following this therapy, antegrade blood flow was achieved in the EIA and the signs and symptoms of acute limb ischemia disappeared (Figure 1C and Video 2). Arterial duplex ultrasonography just after this procedure revealed a retrograde arterial dissection flap without significant stenosis (Figure 1D-E and Video 3). In addition, a triphasic blood-flow pattern was observed in the EIA (Figure 1E). During coronary intensive care, intravenous low-dose nitroglycerin and unfractionated heparin were administered for 48 hours. The in-hospital follow-up of the patient was uneventful, and there were no signs and symptoms of peripheral embolism. Arterial duplex ultrasonography, performed 2 weeks after hospital discharge, showed that there was no residual stenosis and that the dissection flap was sealed.Arterial dissection is an infrequent clinical entity encountered during CAG. Remarkably, even though vasospasm and compression to the access site were other contributing factors, acute EIA occlusion due to retrograde dissection is an extremely rare event. As was shown in our case, medical therapy, including intravenous nitroglycerin and unfractionated heparin, could potentially allow the resolution of the total occlusion of the EIA without necessitating percutaneous transluminal angioplasty or stenting.

Transcaval TAVR on A LVAD Patient Presenting with Cardiogenic Shock

Introduction Aortic insufficiency (AI) following left ventricular assist device (LVAD) placement is a serious, well established complication. Transcatheter aortic valve replacement (TAVR) has been successfully used in LVAD patients developing AI. However, femoral/iliac arterial access required for TAVR is not always possible due to arterial calcifications and small arterial size. Transcaval approach is a novel alternative percutaneous catheter route from the IVC, through the retroperitoneal space, into the abdominal aorta. Transcaval TAVR in LVAD patients with severe AI has not been described. CASE Patient is a 28 year old female with history of postpartum STEMI secondary to spontaneous LAD/LCX dissection requiring CABG with subsequent cardiogenic shock requiring emergent LVAD (HeartMate 3) placement. One month following LVAD implantation, she presents with intractable nausea and vomiting. Physical exam illustrates a cachectic female who was hypotensive, tachycardic, with cool extremities. Laboratory evaluation reveals elevated lactate, transaminases and creatinine. Abdominal CTA shows a prior dissection in the infrarenal abdominal aorta, occlusion of the right external iliac artery and stenosis in the left external iliac artery. On echocardiography, there is severe, continuous, aortic regurgitation increased in severity compared to baseline. Right heart catheterization illustrates right atrial pressure 18 mmHg, pulmonary artery pressure 53/25 mmHg, pulmonary wedge pressure 24 mmHg, and cardiac index 1.3 L/min/m2. Patient is referred for urgent TAVR via transcaval access due to her stenotic and small sized iliac arteries. A pigtail was inserted in the left femoral artery and advanced to the abdominal aorta and another pigtail was inserted in the right femoral vein and advanced to the IVC to align with the aorta one. From the IVC, an astato wire was crossed into the aorta using wats to electrify the wire. A Sapien 3 valve was deployed. The caval aortic fistula was closed with a covered aortic stent. Final angiography showed complete occlusion of the fistula. Post intervention, patient experienced immediate improvement with resolution of cardiogenic shock. At three months, she remained asymptomatic and echocardiogram showed a well seated valve with no AI. DISCUSSION We present an urgent transcaval TAVR performed for a LVAD patient presenting with cardiogenic shock due to AI. Transcaval TAVR is a promising intervention that can be successfully used in LVAD patients developing AI with challenging iliofemoral arterial access.

Lower limb ischemia cured by stimulation electrode implantation assisted with microendoscopic discectomy system: A case report

A 58-year-old male patient diagnosed with thromboangiitis obliterans (Fontaine stage IV) was recently treated with microendoscope discectomy system-assisted spinal cord stimulation electrode implantation and cured by department of vascular surgery combined with department of spinal surgery at Peking University People's Hospital. The patient suffered from cold injury to the right foot 14 years ago, which was cold, painful, numb, and then the toe was ulcerated and gangrene. Only the right foot small toe was left. The right foot skin was swollen from the toe to the proximal segment 1 year ago, accompanied by resting pain. Both pain and autologous bone marrow stem cell transplantation were ineffective. The above symptoms were aggravated three months ago, and the pain was severe. The visual analogue score was 10 points. A high amputation of the left lower extremity was performed 30 years ago due to trauma. Physical examination: the bilateral femoral artery was weak, and the right radial artery, posterior tibial artery, and dorsal artery were not touched. Buerger sign (+). Auxiliary examination: angiography of both lower extremities showed complete occlusion of the bilateral external iliac artery and its distal end. The percutaneous oxygen partial pressure was measured to be 30 mmHg on the right side of the iliac crest. The operation was performed under the local anesthesia. After X-ray positioning, the body projection of the lumbar vertebrae 1-2 lamina gap was marked. The skin had a 1.8 cm incision on the caudal side 2 cm from the mark. Then the dilators were used, and the working sleeve was tilted to the lumbar vertebrae 1-2 lamina gap. The microendoscope discectomy system was installed, the electrode was directly placed into the epidural space from the interlamina space under the microendoscope, the vascular surgeon adjusted the position of the electrode in the spinal canal under fluoroscopy, then connected the stimulator, adjusted the current until the patient had the lower limb fever, fixed electrode position, removed the microendoscope discectomy system after hemostasis under the microendoscope, used the guide needle to lead the electrode through the lumbar subcutaneous and then sutured the incision. After the operation, the electrode was connected to the temporary stimulator to stimulate for several minutes, the patient felt numbness in his lower limbs. In less than one hour, the skin temperature of the affected limb increased, and the painkiller could be stopped while sleeping. After 1 week, the skin temperature of the affected limb increased, and the percutaneous oxygen partial pressure of the foot and ankle was 36 mmHg, and the pain improved, and the score was reduced to 2 points. One month after surgery, the patient underwent permanent stimulator implantation. The pain disappeared after 3 months and half year of follow-up, and the score was reduced to 1 point. Microendoscope discectomy system-assisted spinal cord stimulation electrode implantation can complete the operation quickly, safely and effectively, and greatly reduce the number of intraoperative fluoroscopy and reduce the occurrence of complications.

Inferior Mesenteric Artery Aneurysm with Occlusion of Celiac, Superior Mesenteric and External Iliac Artery

Inferior Mesenteric Artery Aneurysm with Occlusion of Celiac, Superior Mesenteric and External Iliac Artery

Treatment of an external iliac artery chronic total occlusion using alternate access sites

BackgroundWith the advent of endovascular techniques, alternate sites such as the pedal and radial arteries can now be accessed when treating peripheral arterial disease to reduce procedural complications, shorten recovery time, and improve patient comfort. However, a paucity of literature exists on the availability of support devices that can be utilized during challenging cases.Case presentationA 70 year-old female patient presented for evaluation of severe lifestyle-limiting left-sided claudication refractory to maximal medical therapy. Angiography revealed a chronic total occlusion of the left external iliac artery, which was treated successfully by percutaneous intervention via a primary transpedal approach and with the assistance of the Outback® Elite re-entry device. The patient was discharged 2 h after the procedure and reported significant symptom improvement at follow-up.ConclusionThis case highlights a newly adopted endovascular approach through an alternate access site and illustrates how the Outback® Elite device can be used as an adjunctive tool in the treatment of complex lower-extremity vascular lesions.

Supervised Exercise Therapy or Endovascular Revascularization for Patients with Intermittent Claudication due to an Iliac Artery Obstruction? The Super Study

Introduction - The optimal treatment strategy for patients with intermittent claudication (IC) due to an iliac artery obstruction is as yet unclear. Should patients be referred for immediate Percutaneous Transluminal Angioplasty (PTA) or supervised exercise therapy (SET) and deferred PTA if SET fails? Methods - This multi-center randomized controlled trial included 240 patients from 18 hospitals in the Netherlands with IC due to a > 50% common or external iliac artery stenosis or occlusion, and a walking distance 100-300 meters on a treadmill (3.2 km/h, 10% incline). Patients were randomly allocated to PTA with or without stent, or SET, stratified for maximum walking distance (MWD) at baseline and concomitant SFA stenosis or occlusion. PTA was carried out according to local practice. SET comprised a 6 months program supervised by a dedicated physiotherapist twice a week during the first 12 weeks, once a week during the next 8 weeks and once every two weeks during the last 4 weeks. Primary endpoints were MWD on a treadmill (3.2 km/h, 10% incline) and disease specific quality of life (Qol) measured with the VascuQol questionnaire after 1 year follow-up. Analysis was performed according to the intention-to-treat principle. To take into account the repeated measurements structure of the data differences between MWD and VascuQol sumscore were assessed with a linear mixed model with a Toeplitz covariance structure. Results - Between November 2010 and May 2015, 114 patients were allocated to SET, 126 to PTA. Compliance to SET was poor; after 1 month 75/114 (66%) patients attended the program, declining to 68/114 (60%) and 57/114 (50%) after 3 and 6 months, respectively. Ten (8%) of the patients allocated to PTA did not receive the intervention, which was technically successful in 112/116 (97%) of the remaining patients. Five patients had a minor complication after PTA and 6 a major complication necessitating endovascular or surgical resolution. Some 90/114 (79%) patients allocated to SET completed one year follow-up, and 104/126 (83%) allocated to PTA. The mean MWD improved from 187 to 561 meters in the SET group and from 196 to 574 meters in the PTA group, (p=0.693) The VascuQol sumscore improved from 4.24 in the SET group to 5.58, and from 4.28 in the PTA group to 5.88, (p=0.048). Yet, in both groups the improvement in VascuQol sumscore was more than the minimally important clinical difference of 1.19 (derived from 100 participants of the SUPER study). Some 33/114 (29%) of patients allocated to SET had a PTA within one year, and 2/114 (2%) additional surgical revascularization (SR). Some 10/126 (8%) patients allocated to PTA had an additional PTA within one year and another 10/126 (8%) had SR. Conclusion - Both a strategy of immediate PTA, and SET with deferred PTA in case of SET failure improve MWD on a treadmill and disease specific Qol of patients with IC due to an iliac artery obstruction. It seems reasonable to start with SET in these patients and accept a 30% failure rate. The cost-effectiveness analysis of this RCT will further define clinical decision making.