Postoperative Ankle-brachial Index Research Articles

Prospective evaluation of automated vascular analysis for ilio-femoral artery lesions before and after percutaneous endovascular aortic repair

BackgroundThis study was conducted to evaluate the differences between pre- and postoperative access conditions in percutaneous endovascular aortic repair (PEVAR).MethodsBetween December 2021 and October 2023, PEVAR was performed on 61 patients using the Perclose ProStyle (Abbott Vascular). Enhanced computed tomography and ankle-brachial index tests were performed preoperatively and postoperatively. The inner diameter and area of the iliofemoral artery were automatically measured, and the pre- and postoperative values were compared (114 legs). The same analysis was performed on 12 legs with previous groin operations; open surgical EVAR was performed in 9 legs, an endarterectomy of the femoral artery in 1, and a femoropopliteal bypass in the other leg.ResultsAll patients were discharged without surgical site infections, lymphatic fistulas, or retroperitoneal haematomas. There were no significant differences between the pre-and postoperative inner diameter and inner area of the external iliac artery and common femoral artery. There were no significant differences between the preoperative and postoperative ankle-brachial index tests. In 12 legs with a previous groin operation, the postoperative ankle-brachial index tests and inner diameter and area of the external iliac artery and common femoral artery were statistically equal to the preoperative values.ConclusionsThis study can support the safety of percutaneous endovascular aortic repair, even in patients with redo groin operations.

Vascular resistance index and the immediate hemodynamic success of lower limb distal artery revascularization.

Revascularization surgery is used to attempt to restore blood flow to the foot in patients with critical ischemia (CI) caused by peripheral arterial occlusive disease of the lower limbs (LL). Ultrasonography with Doppler (USD) SAH emerged in recent years as a highly valuable method for planning this surgical intervention. To evaluate the relationship between the resistance index (RI), measured with USD, and immediate hemodynamic success of LL revascularization surgery in patients with CI. The study design was a prospective cohort assessing 46 patients with LL CLI who underwent operations to perform infrainguinal revascularization by angioplasty or bypass from August 2019 to February 2022. All patients underwent preoperative clinical vascular assessment with USD including measurement of the RI of distal LL arteries, LL arteriography, and measurement of the ankle-brachial index (ABI). All patients had their ABI measured again in the immediate postoperative period. Forty-six patients were assessed, 25 (54.3%) of whom were male. Age varied from 32 to 89 years (mean: 67.83). Hemodynamic success was assessed by comparison of preoperative and postoperative ABI, showing that hemodynamic success was achieved in 31 (67.4%) patients after revascularization surgery (ABI increased by 0.15 or more). A positive correlation (p ≤ 0.05) was observed between the RI of the distal revascularized LL artery and immediate hemodynamic success assessed by ABI (lower RI and hemodynamic success). This study observed a positive correlation between the resistance index of the distal artery and immediate hemodynamic success of lower limb revascularizations, as assessed by the ankle-brachial index, so that the lower the RI the greater the hemodynamic success achieved.

Aortic endarterectomy in patients with severe multivessel paravisceral and aortoiliac occlusive disease

ObjectiveAortic endarterectomy (AE), once a treatment of choice for aortoiliac occlusive disease, is now rarely performed in favor of endovascular procedures or open aortobifemoral bypass. However, in select patients with paravisceral or aortoiliac occlusive disease, AE remains a viable alternative for revascularization, either as a primary procedure or after prior interventions have failed. Here, we evaluated outcomes for an extended series of patients undergoing paravisceral or aortoiliac endarterectomy, demonstrating that these procedures can be an excellent alternative with acceptable morbidity and mortality in properly selected patients. MethodsA single institution retrospective review of 20 patients who underwent AE from 2017 to 2023 was performed. ResultsFive patients (25%) underwent paravisceral endarterectomy and 15 (75%) underwent aortoiliac endarterectomy. There were no perioperative mortalities. One paravisceral patient died 3 months postoperatively from complications of pneumonia. Three patients in the paravisceral group required reinterventions; one acutely due to thrombosis of the superior mesenteric artery (SMA) requiring extension of the endarterectomy and patch angioplasty on postoperative day 0, one due to stenosis at the distal edge of the endarterectomy 1 month postoperatively, successfully treated with SMA stenting, and one at 10-month follow-up due to SMA stenosis at the distal aspect of the endarterectomy, also successfully treated with SMA stenting. With these reinterventions, the 1-year primary patency in the paravisceral group was 40%, primary-assisted patency was 80%, and secondary patency was 100%. In the aortoiliac group, 1-year primary, primary-assisted, and secondary patency were 91%, 91%, and 100%, respectively. One patient developed iliac thrombosis 10 days postoperatively owing to an intimal flap distal to the endarterectomy site. She and one other patient, a young man with an undefined hypercoagulable disorder, ultimately required neoaortoiliac reconstructions at 18 and 32 months postoperatively, respectively (the latter in the setting of stopping anticoagulation). The remaining 13 patients experienced no complications. All patients had rapid resolution of clinical symptoms, and median postoperative ankle-brachial indexes of 1.06 on the right and 1.00 on the left, representing a median improvement from preoperative ankle-brachial indexes of +0.59 on the right and +0.56 on the left (P < .01 and P < .01). ConclusionsIn this series of 20 patients undergoing paravisceral and infrarenal aortoiliac endarterectomy, AE was associated with no perioperative mortality, relatively low and manageable morbidity, and excellent clinical outcomes in patients with both paravisceral and aortoiliac occlusive disease. SMA-related early reintervention was not uncommon in the paravisceral group, and attention should be given particularly to the distal endarterectomy site. AE remains a viable treatment for severe multivessel paravisceral or aortoiliac occlusive disease isolated to the aorta and common iliac arteries in select patients.

Trapdoor endarterectomy for coral reef plaque of the paravisceral aorta in the modern era

Coral reef atherosclerosis of the paravisceral aorta is a rare disease whose description is confined to before contemporary vascular surgical techniques. This study aims to describe the characteristics and outcomes of patients with coral reef aorta treated with trapdoor endarterectomy at a single high-volume quaternary referral center since 2010. From 2010 to 2022, 14 patients with coral reef aorta were treated with trapdoor endarterectomy. The patient data were obtained via a retrospective medical record review. The patients were predominantly women (79%) with a median age of 65 years (interquartile range [IQR], 60-70 years). The patients universally had a tobacco smoking history and hypertension. More than 85% had previously diagnosed carotid stenosis. Two patients (14%) had undergone prior aortofemoral reconstruction, and one patient (7%) had undergone prior axillobifemoral bypass. The most common presenting symptoms were claudication (71%), chronic mesenteric ischemia (50%), and renovascular hypertension (43%). Of the 14 patients, 8 (57%) underwent isolated endarterectomy and 6 (43%) underwent concomitant aortobifemoral bypass. In addition, 13 patients (93%) required a supraceliac aortic clamp position with a median clamp time of 23 minutes (IQR, 20-30 minutes). The median estimated blood loss was 1650 mL (IQR, 1025-3000 mL). A cell saver was used in 13 procedures (93%), with a median transfusion of 563 mL (IQR, 231-900 mL). The median operative time was 341 minutes (IQR, 315-416 minutes). Eight patients (57%) experienced acute kidney injury in the postoperative period with a peak creatinine of 1.96 mg/dL (IQR, 1.50-2.84 mg/dL). The median length of stay was 11 days (IQR, 6-16 days), with an intensive care unit stay of 4 days (IQR, 2-7 days). One patient (7%) required reoperation in the immediate perioperative period for a retroperitoneal hematoma. The postoperative ankle brachial index increased from a median of 0.58 (right) and 0.57 (left) bilaterally in the preoperative period to 1.09 (right) and 1.10 (left) postoperatively. Eight patients (57%) had follow-up data available for >2 years postoperatively, with five patients (36%) having follow-up data available for >3 years. Two major adverse cardiac events were reported at the last follow-up. One patient reported mild recurrent symptoms of chronic mesenteric ischemia during 3 years of postoperatively, with no concurrent imaging findings or loss of patency found on computed tomography angiography. Symptomatic coral reef atherosclerosis of the paravisceral aorta is a complex disease rarely encountered even at high-volume referral centers. These patients can be expected to experience short-term postoperative morbidity and require intensive care. Despite these challenges, trapdoor endarterectomy is a safe and effective procedure for coral reef aorta, and most patients achieve dramatic symptomatic improvement with durable results.

Mid-term results of combined medical and popliteal artery endarterectomy treatment in Buerger's disease

Aim: Our aim in this article is to present the mid-term results of the best preoperative and postoperative medical treatment and analgesia treatment in patients with advanced Buerger's disease who underwent saphenous patchplasty and saphenous distal bypass after endarterectomy to the popliteal artery or trifurcation area. Material and Methods: Between 2015 and 2023, we operated on 83 patients, diagnosed with Buerger's disease, who were in the chronic stage of the disease, and whose advanced imaging was performed. Preoperative, postoperative, and 1st year control evaluations were determined according to Rutherford, Fontaine classification, and Ankle-Brachial Indexes. Medical treatments of the patients were organized by the vascular surgery team and algology department. After determining the surgical approach strategy according to the imaging of the patients, saphenous patchplasty and anatomical bypass were performed. Results: The mean preoperative ankle-brachial index was 0.305, the mean postoperative ankle-brachial index was 0.644, and the mean 1-year ankle-brachial index was 0.629 in 83 patients included in the study. Statistically significant improvements were observed in the Rutherford and Fontaine classifications. (p-value &lt; 0,001) Amputation was performed in 9.6% of patients within 1 year. Conclusion: Good clinical results and limb salvage can be achieved with a combined medical and surgical treatment approach in advancedstage patients who do not respond despite optimal medical treatment. Provided that patients quit smoking, good determination of the target surgical site, Saphenous patchplasty, and Saphenous distal bypass applied after endarterectomy in suitable patients are supported with good medical and analgesia treatment, the results will improve further.

Side-by-side deployment of gore excluder legs at a narrow terminal aorta for endovascular aneurysm repair.

A narrow terminal aorta is a risk factor for endograft occlusion after endovascular aneurysm repair. To minimize limb complications, we used Gore Excluder legs positioned side-by-side at the terminal aorta. We investigated the outcomes of our strategy for endovascular aneurysm repair in patients with a narrow terminal aorta. We enrolled 61 patients who underwent endovascular aneurysm repair with a narrow terminal aorta (defined as < 18mm in diameter) from April 2013 to October 2021. The standard procedure involves complete treatment with the Gore Excluder device. When other types of main body endografts were used, they were deployed proximal to the terminal aorta, and we used the Gore Excluder leg device in the bilateral limbs. Postoperatively, the intraluminal diameter of the legs at the terminal aorta was measured to assess the configuration. During the follow-up period (mean: 2.7 ± 2.0years), there were no aorta-related deaths, endograft occlusions, or leg-related re-interventions. There were no significant differences between the pre- and postoperative ankle-brachial pressure index values in the dominant and non-dominant legs (p = 0.44 and p = 0.17, respectively). Postoperatively, the mean difference rate (defined as [dominant leg diameter-non-dominant leg diameter]/terminal aorta diameter) was 7.5 ± 7.1%. The difference rate was not significantly correlated with the terminal aortic diameter, calcification thickness, or circumferential calcification (r = 0.16, p = 0.22; r = 0.07, p = 0.59; and r = -0.07, p = 0.61, respectively). Side-by-side deployment of Gore Excluder legs produces acceptable outcomes for endovascular aneurysm repair with a narrow terminal aorta. The endograft expansion at the terminal aorta is tolerable without influencing calcification distribution.

Trapdoor Endarterectomy for Coral Reef Plaque of the Paravisceral Aorta in the Modern Era

Coral reef atherosclerosis (CRA) of the paravisceral aorta is a rare disease whose description is largely confined prior to contemporary vascular surgical techniques. This study aims to describe the characteristics and outcomes of patients with CRA treated with trapdoor endarterectomy (TEA) at a single high-volume quaternary referral center since 2010. From 2010 to 2022, 14 patients were identified who underwent TEA for symptomatic CRA. Data on patient demographics, operative details, hospital course, and outpatient follow-up were obtained via retrospective chart review. Patients were predominantly female (71%) with a median age of 65 years (interquartile range [IQR], 63-70) and had traditional vascular risk factors. Over 85% had previously diagnosed carotid stenosis; two patients (14%) had prior aortofemoral reconstruction, and one (7%) had prior axillobifemoral bypass. The most common presenting symptoms were claudication (64%), chronic mesenteric ischemia (50%), and renovascular hypertension (43%). Eight patients (57%) received isolated TEA and six (43%) received concomitant aortobifemoral bypass (Table I). Thirteen patients (93%) required a supraceliac aortic clamp position with a median clamp time of 26 minutes (IQR, 20-30 minutes). Median estimated blood loss was 1650 mL (IQR, 1025-3750 mL). Cell saver was used in 13 procedures (93%) with median transfusion of 563 mL (IQR, 231-900 mL). Median operative time was 341 minutes (IQR, 315-316 minutes). Eight patients (57%) had acute kidney injury in the postoperative period with peak creatinine of 2.02 (IQR, 1.58-2.95) (Table II). Length of stay was 13 days (IQR, 7-16 days) with an intensive care unit stay of 4 days (IQR, 2-7 days). Two patients (14%) required reoperations in the immediate perioperative period, one for retroperitoneal hematoma and one for target vessel (superior mesenteric artery) occlusion. Postoperative ankle-brachial indices were increased from a median of 0.52 bilaterally in the preoperative period to >1 postoperatively. Eight patients (57%) had follow-up over 2 years after TEA, with five patients (36%) having follow-up over 3 years. Three major adverse cardiac events were reported at last follow-up. Just one patient reported persistent symptoms of chronic mesenteric ischemia at 11 years after TEA. Symptomatic CRA of the paravisceral aorta is a complex disease rarely encountered even at a high-volume quaternary referral center. These patients can be expected to experience short-term postoperative complications and require intensive care. Despite these challenges, trapdoor transaortic endarterectomy is a safe, effective procedure for CRA and most patients achieve dramatic symptomatic improvement with durable results.Table IGeneral operative characteristics (n = 14)VariablesMedian [IQR] or No. (%)Procedure types Trapdoor endarterectomy8 (57) Trapdoor endarterectomy with aortobifemoral bypass6 (43)Starting clamp position Supraceliac13 (93) Supramesenteric1 (7)Subsequent clamp position Infrarenal10 (71) None4 (29)Aortic closure Primary closure12 (86) Bovine patch angioplasty1 (7) Dacron patch angioplasty1 (7)Revascularized vessels Celiac3 (21)Eversion endarterectomy3 (100) Superior mesenteric artery5 (36)Eversion endarterectomy4 (80)Catheter embolectomy1 (20) Left renal5 (36)Eversion endarterectomy4 (80)Bypass graft1 (20) Right renal3 (21)Eversion endarterectomy3 (100) Bilateral renals3 (21)Eversion endarterectomy3 (100) IMA1 (7)Eversion endarterectomy1 (100)Cold renal perfusion8 (57)Estimated blood loss, mL1650 [1025-3750]Intraoperative transfusion, units2 [1-4]Cell saver13 (93) Volume transfused, mL563 [231-900]Suprarenal clamp time, minutes (n = 13)26 [20-30]Operative time, minutes341 [315-416]IQR, Interquartile range. Open table in a new tab Table IIPostoperative course, (n = 14)VariableMedian [IQR] or No. (%)Inpatient complications Anemia14 (100) Acute kidney injury8 (57)Creatinine (peak)2.02 [1.58-2.95]Dialysis1 (7) Cardiopulmonary complications5 (36) Reoperation2 (14)Retroperitoneal hematoma1 (7)Secondary intervention1 (7) Ileus2 (14) Colitis2 (14) Deep vein thrombosis1 (7) Myocardial infarction1 (7) Infection1 (7) Death1 (7)Intensive care unit admission14 (100) Length of stay, days4 [2-7]Total length of stay, days13 [7-16]Laboratory tests Blood urea nitrogen (preoperative)14 [10-16] Creatinine (preoperative)1.01 [0.91-1.31] Creatinine (discharge)1.06 [0.70-1.35]Hemodynamics Right ABI (preoperative), n = 100.52 [0.34-0.90] Left ABI (preoperative), n = 100.52 [0.38-0.81] Right ABI (postoperative op), n = 91.12 [1.06-1.16] Left ABI (postoperative), n = 91.10 [1.09-1.15]Readmission within 30 days3 (21)Duration of follow-up, years2 [0.5-3.0]Outpatient complications, time postoperative3 (21) Ureteral stricture, 2 months1 (7) Loss of primary patency, 18 months1 (7) New chronic mesenteric ischemia, 8 years1 (7)Amputation0 (0)Persistent symptomatology at last follow-up (n = 13)1 (7) Claudication or rest pain0 (0) Mesenteric angina1 (7)Major adverse cardiac events at last follow-up3 (21) Death2 (14) Myocardial infarction1 (7)IQR, Interquartile range. Open table in a new tab

Predictors for Distal Revascularization Following Femoral Endarterectomy in Chronic Limb-Threatening Ischemia Patients.

This study aims to identify the clinical variables which are predictive for the benefit of concomitant distal revascularization (DR) to prevent Chronic limb-threatening ischemia (CLTI) progression and the need for major limb amputation. This is a retrospective cohort study of patients who presented with lower limb ischemia and required at least femoral endarterectomy (FEA), recruited over a period of 15years (2002-2016). The patient cohort was divided into three groups based on the type of intervention: A (FEA alone), B (FEA + catheter-based intervention/(CBI)), and C (FEA + surgical bypass (SB)). The primary endpoint was to identify independent predictors for the use of concomitant DR (CBI or SB). Secondary endpoints were amputation rate, length of stay, mortality rate, postoperative ankle-brachial index and complications, readmission rate, re-intervention rate, resolution of symptoms and wound status. A total of 400 patients were included, 68.0% were males. Most presenting limbs were at Rutherford class (RC) III and WIfI stage 2, with an ankle-brachial index (ABI) of .47 ± .21 and a TASC II class C lesion. No significant differences were found in the primary-assisted and secondary patency rates between the three groups (P > .05, in all). In the multivariate analyses, clinical variables associated with DR were hyperlipidemia (hazard ratio (HR) 2.1-2.2), TASC II D (HR 2.62), Rutherford class 4 (HR 2.3) and 5 (HR 3.7), as well as WIfI stage ≥3 (HR 1.48). Femoral endarterectomy is sufficient to treat intermittent claudication. However, patients in whom rest pain, tissue loss or TASC II D anatomic lesion severity are present may benefit from concomitant distal revascularization. Taking into consideration the overall assessment of operative risk factors for each individual patient, proceduralists should have a lower threshold for performing early or concomitant distal revascularization to reduce CLTI progression including additional tissue loss and/or major limb amputation.

Outcomes of Surgical Revascularization for Acute Limb Ischemia in COVID-19 Patients Comparing to Noninfected Cohort: A Single-Center Observational Prospective Study

The purpose of the study was to compare the clinical presentation, management, and outcomes of surgical revascularization for acute limb ischemia (ALI) in 2 groups of patients-with and without SARS-CoV-2 infection. During the 2years (01.01.2020-31.12.2021) all consecutive patients diagnosed with ALI and treated with urgent revascularization were prospectively enrolled. Based on the results of polymerase chain reaction swab for SARS-CoV-2 infection patients were allocated to group A-infected or group B-noninfected. Demographic characteristics, clinical, imaging, laboratory data, and details of treatment were collected prospectively. The composite endpoint of major amputation and/or death at 30days after surgery was defined as main study outcome. The postoperative ankle-brachial index value, reinterventions, complications, and length of hospital stay were considered as secondary outcomes. Overall, 130 patients (139 limbs with ALI) were analyzed-21 patients (23 limbs) in group A and 109 patients (116 limbs) in group B. The anatomical site of arterial occlusion, duration, and severity of ischemia did not differ significantly between the groups. Patients with COVID-19 had significantly shorter time from ALI onset till administration of the first dose of anticoagulant: 8 (2.5-24) hr vs. 15.7 (6-72) hr in group B, P=0.02. Vascular imaging was performed before intervention only in 5 (23.8%) infected patients compared to 78 (71.5%) patients in group B, P<0.001. The main outcome was registered in 38 (29.2%) patients, significantly more frequent in infected cohort: 12 (57.1%) patients in group A versus 26 (23.8%) in group B, P=0.003. Difference was preponderantly caused by high mortality in group A-9 (42.8%) patients, compared to 17 (15.5%) patients in group B, P=0.01. The difference in the rate of limb loss was not statistically significant: 4 (17.3%) limbs were amputated in COVID-19 patients and 12 (10.3%) limbs-in noninfected patients (P=0.3). Combination of ALI and COVID-19 resulted in increased 30-day mortality-risk ratio (RR) 2.7 (95% confidence interval [CI]: 1.42-5.31), P=0.002, but did not lead to significantly higher amputation rate-RR 1.6 (95% CI: 0.59-4.75), P=0.32. In group A initial admission of the patient in the intensive care unit was an independent risk factor for amputation/death. Excepting systemic complications which were more frequently registered among COVID-19 patients: 7 (33%) cases vs. 14 (12.8%) in group B, P=0.04; no differences in other secondary outcomes were observed between the groups. Study demonstrates the significant negative impact of COVID-19 upon the 30-day amputation-free survival in patients undergoing urgent surgical revascularization for ALI. The difference in outcome is influenced by higher rate of mortality among infected patients, rather than by the rate of limb loss. Severity of COVID-19, namely requirement of intensive care, mostly determines the outcome of ALI treatment.

Midterm Outcomes of Endovascular Therapy for TASC II D Femoropopliteal Lesions with Critical Limb Ischemia: A Retrospective Analysis

This study evaluated the midterm results of endovascular therapy (EVT) for Trans-Atlantic Inter-Society (TASC) II D femoropopliteal lesions in patients with critical limb ischemia (CLI). Fifty seven limbs of 54 patients with CLI due to TASC II D femoropopliteal lesions who underwent EVT at the First Hospital of Hebei Medical University were retrospectively analysed in a single-centre, observational study. The patient characteristics, endovascular procedural details, freedom from target lesion revascularization (TLR), patency rates, ulcer healing rate, and limb salvage rate were accessed. The patients' mean age was 68.2±8.2years. All patients were treated by EVT. The final technical success rate was 98.2% (56/57). There were 23 cases of pain at rest, 18 cases of ulcer, and 15 cases of gangrene. The median length of the treated segment was 286±42mm (56/56) and the mean number of stents placed per patient was 2.0±0.8 (49/56). The postoperative ankle-brachial index was significantly higher than that of the preoperative ankle-brachial index (P<0.05). The perioperative complication rate was 10.7% (6/56). The restenosis or occlusion rate was 44.6% (25/56). The estimated rates of freedom from TLR at 1year, 2years, and 3years were 86.8%, 67.0%, and 62.5%, respectively. A univariate analysis showed that predictors of freedom from TLR were the number of runoff vessels, length of the lesion, and complexity of the lesion, while predictors for restenosis or occlusion were the length and the complexity of the lesion. The ulcer healing rate was 93.8%. The limb salvage rates were 76.4%, 74.4%, and 70.9% at 1, 2, and 3years after treatment, respectively. The midterm outcomes of EVT for TASC II D femoropopliteal lesions in patients with CLI indicated that this treatment approach is safe and effective and is clinically applicable.

Prevalence of chronic opioid use in patients with peripheral arterial disease undergoing revascularization.

Opiate use, dependence, and the associated morbidity and mortality are major current public health problems in the United States. Little is known about patterns of opioid use in patients with peripheral arterial disease (PAD). The purpose of this study was to identify the prevalence of chronic preoperative and postoperative prescription opioid use in patients with PAD. A secondary aim was to determine the demographic, comorbid conditions, and operative characteristics associated with chronic opioid use. Using a single-institution database of patients with PAD undergoing open or endovascular lower extremity intervention from 2013 to 2014, data regarding opiate use and associated conditions were abstracted for analysis. Patients were excluded if they did not live in North Carolina or surgery was not for PAD. Preoperative (PreCOU) and postoperative chronic opioid use (PostCOU) were defined as consistent opioid prescription filling in the 3months before and after the index procedure, respectively. Opioid prescription filling was assessed using the North Carolina Controlled Substance Reporting System. Demographics, comorbid conditions, other adjunct pain medication data, and operative characteristics were abstracted from our institutional electronic medical record. Associations with PreCOU were evaluated using the t test, Wilcoxon test, or two-sample median test (continuous), or the χ2 or Fisher exact tests (categorical). A total of 202 patients undergoing open (108; 53.5%) or endovascular (94; 46.5%) revascularization for claudication or critical limb ischemia were identified for analysis. The mean age was 64.6years, and 36% were female. Claudication was the indication for revascularization in 26.7% of patients, and critical limb ischemia was the indication in 73.3% of patients. The median preoperative ankle-brachial index (ABI) was 0.50. Sixty-eight patients (34%) met the definition for PreCOU. PreCOU was associated with female gender, history of chronic musculoskeletal pain, benzodiazepine use, and self-reported illicit drug use. Less than 50% of patients reported use of non-opiate adjunct pain medications. No association was observed between PreCOU and pre- or postoperative ABI, or number of prior lower extremity interventions. Following revascularization, the median ABI was 0.88. PreCOU was not associated with significant differences in postoperative complications, length of stay, or mortality. Overall, 71 patients (35%) met the definition for PostCOU, 14 of whom had no history of preoperative chronic opiate use. Ten patients with PreCOU did not demonstrate PostCOU. Chronic opiate use was common in patients with PAD with a prevalence of approximately 35%, both prior to and following revascularization. Revascularization was associated with a termination of chronic opiate use in less than 15% of patients with PreCOU. Additionally, 10% of patients who did not use opiates chronically before their revascularization did so afterwards. Patients with PAD requiring intervention represent a high-risk group with regards to chronic opiate use. Increased diligence in identifying opioid use among patients with PAD and optimizing the use of non-narcotic adjunct pain medications may result in a lower prevalence of chronic opiate use and its attendant adverse effects.

Feasibility of Photo-Optical Transcutaneous Oxygen Tension Measurement During Revascularization of the Lower Extremity

ObjectivesA novel approach in the evaluation of peripheral arterial disease is the photo-optical oxygen tension measurement (pTCpO2). This modality is suggested to be more practical in use in comparison to standard electro-chemical oxygen tension measurement. Hence, pTCpO2 might be of added value to evaluate revascularization of the lower extremities peri-procedural. We conducted a preliminary feasibility study to analyze the potential of pTCpO2 during revascularization. MethodsTen patients scheduled for revascularization of the lower extremities were enrolled. pTCpO2 values of the affected lower extremity were measured pre-operatively, during revascularization and after revascularization. Results were compared to the pre- and postoperative ankle-brachial index (ABI) and to perioperative angiography. Primary endpoint was the feasibility of perioperative pTCpO2 measurement. Secondary endpoints were concordance between pTCpO2, ABI, angiography and clinical outcome. ResultsTwo out of twelve measurements were unsuccessful. Eight out of ten patients experienced significant clinical improvement and pTCpO2 increase. Two patients that did not experience clinical improvement corresponded with no changes in intraoperative angiography and without increase in ABI or pTCpO2. A significant and strong correlation was found between prior and after revascularization ABI and pTCpO2 measurements (r = 0.82 P = 0.04). ConclusionsPhoto-optical transcutaneous oxygen tension measurement may serve as an intraoperative tool to evaluate the success of revascularization. pTCpO2 could be an alternative for the ABI to determine the success of lower extremity revascularization.

Control of Femoral Cannulation with a ProGlide Pre-Closure Device during Cardiac Surgery: Is It Reliable?

BackgroundThe use of ProGlide as a percutaneous vascular closure device in cardiac surgery remains inconclusive. This study investigated the clinical outcomes of using ProGlide in the percutaneous cannulation of femoral vessels in adult cardiac surgery.MethodsFrom September 2017 to July 2018, 131 consecutive patients underwent femoral vessel cannulation during cardiac surgery. The ProGlide (Abbott Vascular Inc., Santa Clara, CA, USA) with percutaneous cannulation was used in 118 patients (mean age, 55.7±15.5 years). The accessibility of femoral cannulation was evaluated through preoperative computed tomography. For cannulation, sonography was routinely used. The postoperative ankle-brachial index (ABI) was used to evaluate femoral artery stenosis.ResultsOf the 118 patients, 112 (94.9%) and 6 (5.1%) underwent minimally invasive cardiac surgery and median sternotomy, respectively. Most femoral cannulations were performed on the right side (98.3%) using 15F to 19F arterial cannulas. The technical success rate of cannulation with ProGlide was 99.2%, with no delayed bleeding or cannulation site-related complications during hospitalization. During follow-up, only 1 patient showed femoral artery stenosis with claudication and was treated with interventional balloon angioplasty. The postoperative ABI revealed no significant difference in functional stenosis between the cannulation and non-cannulation sides (n=86; cannulation vs. non-cannulation, 1.2±0.1 vs. 1.1±0).ConclusionPercutaneous femoral cannulation with ProGlide was safe and feasible in adult cardiac surgery. This technique may be a good alternative option in patients requiring femoral vessel cannulation for cardiac surgery.

Changes in Early Postoperative Toe-Brachial Indices May Reflect Positive or Negative Remodeling

Society for Vascular Surgery guidelines recommend utilization of the ankle-brachial index (ABI) for early postoperative surveillance after infrainguinal revascularizations. However, little guidance exists regarding the ideal timing of the initial postoperative examination. This study sought to investigate the efficacy and optimal timing of these postprocedural noninvasive studies. A retrospective review of all open and endovascular infrainguinal revascularization procedures between July 2014 and November 2019 at a single tertiary referral center was performed. Patient and procedural details as well as preoperative and postoperative ABI and toe-arm indices (TAI) were collected and analyzed. A total of 711 patients underwent infrainguinal revascularization for peripheral arterial disease. Of these, 37.4% (266) did not undergo a postoperative ABI or TAI within 30 days, 0.4% had incompressible ABI and TAI, 2.1% had incompressible ABI with inability to obtain toe pressures, 0.6% had incompressible brachial arteries, and 2.5% were excluded for other reasons. A total of 404 patients had a valid postprocedural ABI or TAI. Locally weighted regression of the TAI values demonstrated early improvement with a steep rise in TAI within the first two days postprocedure followed by continue improvement until a plateau after 20 days (Fig). A small cohort of 36 patients had two studies performed within the initial 30 days from their index procedure. Of these patients, five (13.9%) had a significant decrease (>0.15) in their TAI, 19 (52.8%) had no significant change, and 12 (33.3%) had a significant increase in their TAI. 40% of those with a significant drop in TAI required reintervention within 1 year compared with 30% of those whose TAI increased or did not change. When performed, ABI and TAI are reliable tools to establish baseline arterial perfusion after revascularization, with <5% of studies performed invalidated due to incompressible vessels. Plateau of postprocedural TAI occurs after 20 days, suggesting that immediate baseline studies may not accurately reflect the peak benefit of an intervention, potentially due to ongoing remodeling. However, when serial studies are performed, a decrease in TAI may help to identify patients who require reintervention.

Rehabilitation progress after lower-extremity bypass surgery in patients with peripheral arterial disease with different occlusive lesions.

[Purpose] To examine the differences in rehabilitation progress after lower-extremity bypass surgery for peripheral arterial disease (PAD) depending on the occlusive lesions. [Participants and Methods] This was a retrospective study. We included 50 patients (61 limbs; 38 males and 12 females; mean age, 73 years) who underwent lower-extremity bypass surgery for Fontaine stage 2–3 PAD. The patients were assigned to the aortoiliac (A-I) group (n=23), femoropopliteal (F-P) group (n=18), and below-knee group (n=9). We evaluated the postoperative rehabilitation progress and length of hospital stay of these groups. [Results] The postoperative ankle-brachial pressure index (ABI) of the A-I group was significantly lower than that of the F-P group, although there were no differences before surgery. The progress of rehabilitation and the length of hospitalization showed no significant differences among the three groups. The postoperative date of independent walking was significantly later in the presence of complications than in the absence of complications. [Conclusion] The progress of rehabilitation after lower-extremity bypass surgery did not differ depending on the occlusive lesions, and patients may acquire independent walking ability in approximately 5 days in the absence of postoperative complications.

The effectiveness of percutaneous mechanical thrombectomy in the treatment of acute thromboembolic occlusions of lower extremity.

The objective of this study was to evaluate the effectiveness of percutaneous mechanical thrombectomy as the initial thrombus removal method in the treatment of acute lower extremity ischemia. The patients with acute lower limb ischemia who underwent percutaneous mechanical thrombectomy between August 2016 and February 2018 were retrospectively reviewed. The patients were diagnosed by clinical examination and computed tomography angiography. The percutaneous mechanical thrombectomy was performed as the initial thrombus removal method, followed by anticoagulation therapy. The patients were followed up by clinical examination, imaging, and ankle brachial index (ABI) examination. Thirty-two patients (21 males, 11 females; average age of 68.53 ± 8.05; three cases of grade III, 29 cases of grade IIB) were reviewed. Recanalization of the thromboembolic occlusions were achieved in all patients. ABI significantly (p < 0.01) increased postoperatively (preoperative ABI: 0.51 ± 0.13; postoperative ABI: 0.85 ± 0.65, ABI at three months postoperatively: 0.84 ± 0.66). Eleven patients underwent balloon dilation and three patients had stent placement. Complete thrombus removal was achieved in all patients. The primary patency at 3 months, 6 months, and 12 months postoperatively was 90%, 85%, and 56%, respectively. The secondary patency at 3 months, 6 months, and 12 months postoperatively was 93%, 87%, and 65%, respectively. The immediate result appeared to be effective to use percutaneous mechanical thrombectomy as the first thrombus removal method in the treatment of acute thromboembolic occlusions in the lower extremity, while the midterm result needs to be further improved.

Drug-coated balloons used in peripheral artery disease: experience from a single center

ObjectiveThis retrospective single-center study aimed to analyze immediate and follow-up results of using drug-coated balloons (DCBs) for treating peripheral arterial disease.MethodsIn this study, we identified a total of 75 patients who underwent DCB therapy at our institution. The ankle–brachial index (ABI) was measured before and after intervention. Intermittent claudication and whether there was healing of ulcers were determined by telephone.ResultsThe cohort consisted of 56 men and 19 women aged 38 to 87 years (68 ± 12 years). Twenty-three patients had Rutherford grade III, 15 had Rutherford grade IV, and 37 had Rutherford grade V. Seventeen patients had stents and 18 had the Rotarex system used. The postoperative ABI was significantly greater than the preoperative ABI (0.911 ± 0.173 vs 0.686 ± 0.249). Good results for treatment were obtained. Intermittent claudication and rest pain did not occur in subjects with Rutherford grades III and IV during follow-up. The amputation rate was 4.1% among all patients using DCB therapy during follow-up.ConclusionsDCB therapy is safe and effective for treating peripheral arterial disease in real-world patients. Future prospective studies on this issue are recommended.

Outcomes of femoral artery ligation for treatment of infected femoral pseudoaneurysms due to drug injection

ObjectiveInfected femoral artery pseudoaneurysms (IFAPs) are a known complication of illicit intravenous drug injection. As the opioid crisis in our country continues to worsen, we will likely see more IFAPs and algorithms for management of these patients will need to be elucidated. The aim of this study was to describe the surgical management and outcomes of patients presenting with IFAPs treated with femoral artery ligation. MethodsThis is a single-center, retrospective study of consecutive patients presenting to our institution with IFAPs associated with illicit drug injection between 2004 and 2017 and treated with primary ligation. Primary end points included major adverse limb events (MALE) and death. Baseline demographics, clinical features, and long-term outcomes were recorded. ResultsOver the study period, 60 IFAPs were managed with arterial ligation in 58 patients. Fifty-two percent of patients underwent common femoral artery ligation, 30% of patients underwent a triple ligation (ligation of the common femoral artery, profunda femoris artery, and superficial femoral artery), and 18% of patients underwent ligation of the superficial femoral artery only. The average postoperative ankle-brachial index was 0.47. None of the patients underwent revascularization at the index procedure. In our early experience, four patients (6.6%) underwent delayed revascularization with a prosthetic bypass. Two of the patients subsequently re-presented with infected bypass grafts and required the only major amputations in our series. The mean follow-up was 51.3 months and four patients were lost to follow-up. No differences were identified in MALE between patients undergoing a femoral artery ligation vs a triple ligation. Nine patients (15%) died during the follow-up period and all deaths were unrelated to IFAP treatment; the mean survival from procedure to death was 28 months. ConclusionsWe describe the largest series in the United States of IFAP related to illicit drug use treated with femoral artery ligation and found it is a safe procedure associated with low MALE. Reconstruction is not recommended and is associated with graft infection. Although the mortality rate in these patients was high, it was not related to the ligation procedure.

Comparative Long-term Outcomes of Patients with Aortoiliac Occlusive Disease Limited to Common Iliac Arteries Who Underwent Endarterectomy versus Bypass Grafting

The objective of this study was to compared outcomes of patients with aortoiliac occlusive disease (AIOD), limited to the common iliac artery, who underwent either aortoiliac thromboendarterectomy (AIE) or aortobiiliac bypass grafting (ABIB). A single-center, retrospective analysis of consecutive patients with AIOD who underwent either AIE or ABIB between 2010 and 2019 from a prospective database. Patients with disease extending to the external iliac or common femoral arteries were excluded. Data collected included demographics, cardiovascular risk factors, indication for surgery, preoperative and postoperative ankle brachial indexes (ABIs), estimated blood loss, major adverse events (MAEs), and long-term patency. The study end point was clinical success, defined as improvement in ABIs with resolution of symptoms. MAEs included return to the operating room for any reason, postoperative myocardial infarction, stroke, pneumonia, or venous thromboembolism. Thirty-three patients, who met inclusion criteria, underwent repair for AIOD (AIE: 13; ABIB: 20) at our institution during this time. In both groups, there were more women than men (AIE: 11, ABIB: 10) with a mean age of 55±7 years and 58±6 years in the AIE and ABIB group, respectively. Indication for surgery included disabling claudication in 19 patients, ischemic rest pain in 13 patients, and tissue loss in one patient. No difference in cardiovascular risk factors or AIOD severity was noted between groups. Patients in the AIE group had slightly higher body mass index (30±5 vs. 26±6, P=0.06). Two patients in each group required concomitant renal/mesenteric artery endarterectomy. One patient in the AIE group required bilateral femoral artery exposure and external iliac thrombectomy. MAEs (4 vs. 0) were higher in the ABIB group including, pneumonia in one patient, myocardial infarction in another, return to the operating room for evacuation of hematoma in the third and bypass graft thrombectomy with lower extremity angiography in the fourth patient. There were no differences in the intensive care unit or hospital length of stay between groups. Patients in both groups achieved return of normal ABI and complete resolution of their symptoms. At mean follow-up time of 43.4±25.2 and 52.9±35.4months in the AIE and ABIB group, respectively, there was no symptomatic recurrence or need for reintervention while two patients in the ABIB group died of non-aortic-related issues. Both procedures were safe, effective, and conferred high long-term primary patency with no need for reintervention in patients with AIOD limited to the common iliac arteries.

Efficacy of the Decalcification of Heavily Calcified Femoral Bifurcation Lesions Using a Cavitron Ultrasonic Surgical Aspirator

In the current diabetes era, severe calcified femoral bifurcation lesions extending to the external elastic lamina are sometimes experienced and are technically challenging during conventional endarterectomy. We previously reported an alternative method, a decalcification technique with a Cavitron Ultrasonic Surgical Aspirator (CUSA), for calcified lesions. This study aimed to clarify the efficacy of CUSA decalcification technique. A total of 26 limbs treated with CUSA decalcification from 2014 to 2017 were enrolled and evaluated hemodynamically with ankle-brachial index (ABI) and morphologically with computed tomography angiography (CTA). ABI was measured every 6months, and CTA was performed early after surgery and then annually thereafter. Curved planar reformation images and cross-sectional multiplanar reconstruction images obtained by CTA were used to measure the cross-sectional area of the common femoral artery (CFA). Then, the time courses of the ABI and CFA areas were analyzed. The operative indication was claudication in 80.8%, rest pain in 7.7%, and tissue loss in 11.5% of the cases. A concomitant profundaplasty was performed in 34.6% of the cases. One case of an intraoperative arterial wall perforation was experienced as a procedure-related complication. Hemodynamic success rate was 96.2% (preoperative ABI: 0.37±0.28, postoperative ABI: 0.75±0.15, P<0.0001) and technical success rate was 100.0% (preoperative CFA area: 4.1±5.9mm2, postoperative CFA area: 46.1±17.0mm2, P<0.0001), with clinical improvement achieved in 95.8% of cases. Primary and secondary patency rates of the CFA were 100.0% at 2years postoperatively, and the reintervention-free rate for the ipsilateral limb was 88.5% at 2years postoperatively. Over a median follow-up period of 28.0 months (range, 12.3-67.0 months), the restenosis rate of CFA was 7.6%, when restenosis was defined as a >50% decrease in cross-sectional area. CUSA decalcification is a safe and effective alternative method to treat heavily calcified femoral lesions with a good patency rate and a low restenosis rate.