Severe Peripheral Vascular Disease Research Articles

Case Report: Multiple atherosclerotic plaques at its extreme in synchrony

Peripheral artery (PAD) disease in association with renal artery stenosis is an important association which predicts the severity of the disease. An increase in the number of vessels affected by peripheral artery disease increases the chances of renal artery stenosis. In our case, the patient had primarily presented with anginal chest pain with complaints of claudication which on further investigation was diagnosed to be a triple vessel coronary artery disease along with bilateral subclavian and bilateral renal stenosis. On detailed history taking, risk factors like hypertension and chronic smoking was found to be present in our case which predisposed to peripheral artery disease secondary to atherosclerosis which was diagnosed on further investigations. Although the association of renal artery stenosis is not very rare in cases of severe peripheral vascular diseases, the presence of a triple vessel coronary artery disease in synchrony is what makes it unique. Take away lesson from this case report is importance of early diagnosis of dyslipidemia causing atherosclerosis and its complications. Multiple atherosclerotic lesions in synchrony i.e, bilateral renal artery stenosis with bilateral subclavian artery stenosis with coronary artery triple vessel atherosclerotic disease like in our case and its severity should create awareness among health care individuals and early treatment measures including lifestyle modifications should be considered to avoid such drastic events.

Ultra-Low Contrast Multivessel Orbital Atherectomy–Assisted PCI in a Patient With Severe Peripheral Vascular Disease

Ultra-Low Contrast Multivessel Orbital Atherectomy–Assisted PCI in a Patient With Severe Peripheral Vascular Disease

Case Report: Multiple atherosclerotic plaques at its extreme in synchrony

Peripheral vascular disease in association with renal artery stenosis is an important association which predicts the severity of the disease. An increase in the number of vessels affected by peripheral vascular disease increases the chances of renal artery stenosis. In our case, the patient had primarily presented with anginal chest pain with complaints of claudication which on further investigation was diagnosed to be a triple vessel coronary artery disease along with bilateral subclavian and bilateral renal stenosis. On detailed history taking, risk factors like hypertension and chronic smoking was found to be present in our case which predisposed to peripheral artery disease secondary to atherosclerosis which was diagnosed on further investigations. Although the association of renal artery stenosis is not very rare in cases of severe peripheral vascular diseases, the presence of a triple vessel coronary artery disease in synchrony is what makes it unique. Take away lesson from this case report is importance of early diagnosis of dyslipidemia causing atherosclerosis and its complications. Multiple atherosclerotic lesions in synchrony i.e, bilateral renal artery stenosis with bilateral subclavian artery stenosis with coronary artery triple vessel atherosclerotic disease like in our case and its severity should create awareness among health care individuals and early treatment measures including lifestyle modifications should be considered to avoid such drastic events.

TCTAP C-086 Prophylaxis ECMO-Supported Complex Percutaneous Coronary Intervention in Patient With Severe Left Ventricular Dysfunction and Severe Peripheral Vascular Disease

TCTAP C-086 Prophylaxis ECMO-Supported Complex Percutaneous Coronary Intervention in Patient With Severe Left Ventricular Dysfunction and Severe Peripheral Vascular Disease

Arterialized Vein Bypass Graft Recipient Vessel in Free Tissue Transfer Covering Diabetic Foot Ulcers Complicated by Critical Limb Ischemia.

Limb salvage options are limited in diabetic patients with critical limb ischemia. Soft tissue coverage remains technically demanding with limited recipient vessels for free tissue transfer. These factors make revascularization alone challenging. When open bypass revascularization is possible, venous bypass graft is optimal and functions as a recipient vessel for staged free tissue transfer.The authors present 2 cases using a combination approach of staged venous bypass graft revascularization followed by free tissue transfer with anastomosis to the venous bypass graft resulting in successful limb preservation.Free tissue transfer to a native vessel has limited application in severe peripheral vascular disease patients because early vascular compromise threatens flap survival. In both presented cases, venous bypass graft alone was insufficient to treat their nonhealing wounds, and preoperative angiogram revealed dismal options for free tissue transfer reconstruction. However, previous venous bypass graft provided an operable vessel for free tissue transfer anastomosis. The combination of venous bypass graft and free tissue transfer proved to be ideal for successful limb preservation by providing vascularized tissue to previously ischemic angiosomes, ensuring optimal wound healing capacity. Venous bypass graft is advantageous to native arterial grafts, and its combination with free tissue transfer likely increases graft patency and flap survival. We demonstrate that end-to-side anastomosis to a venous bypass graft is a viable option in these highly comorbid patients with favorable flap outcomes.

987. Retrospective Evaluation of Calcaneal Osteomyelitis Outcomes and Factors for Treatment

Abstract Background Calcaneal osteomyelitis (OM) accounts for 3-10% of all cases; however, there is limited data comparing clinical outcomes between patients with calcaneal OM and non-calcaneal OM of the foot. Methods This was a retrospective, observational cohort study of patients treated with at least 4 weeks of antibiotic therapy or surgical intervention for calcaneal or non-calcaneal OM at the VA St. Louis Health Care System between 1 January 2010 and 30 June 2021. The primary outcome was treatment failure, defined as a follow-up encounter for new surgical intervention or re-initiation of antibiotics within 6 months of completion of initial surgical intervention or antibiotic therapy. Secondary outcomes included individual components of the primary outcome and antibiotic adverse events. The variables of calcaneal OM, poorly controlled diabetes, severe peripheral vascular disease, treatment for ≥2 weeks at a skilled nursing facility, and amputation as part of treatment were included in a univariate analysis and any variables with a p< 0.2 were subsequently placed into a multivariate regression model to determine if any stated variables were independently associated with treatment failure. Results Eighty patients were included, 40 treated for calcaneal OM and 40 treated for non-calcaneal OM. More patients in the calcaneal group had a bone biopsy obtained (62% vs. 35%; p=0.014) and were treated with definitive therapy (77.5% vs. 47.5%; p=0.005). Conversely, more non-calcaneal patients received initial amputations for treatment (12.5% vs. 32.5%; p=0.032). Sixteen (40%) of calcaneal OM patients and 17 (42.5%) of non-calcaneal foot OM patients failed initial therapy (p=0.82). There was no statistically significant difference between the two groups in the re-initiation of antibiotics within 6 months for an infection of the same site (20% vs. 40%; p=0.051) or for unplanned surgery for same site within 6 months (30% vs. 15%; p=0.108). None of the factors in the univariate analysis met criteria to be included in the multivariate logistic regression. Conclusion The clinical outcomes of patients treated for calcaneal OM were not different from those treated for non-calcaneal OM of the foot. Disclosures All Authors: No reported disclosures.

PSAT018 Management of Pheochromocytoma in the Setting of a Patient with Multiple Vasculopathies

Abstract A 66-year-old male with history of Type 2 diabetes and adrenal incidentaloma presented to the hospital with significant left lower limb edema and was found to have severe peripheral vascular disease. CT surgery was consulted and performed an angiogram as well as an angioplasty; however, the patient had severe stenosis and stenting was not possible. Femoral popliteal bypass was planned. Due to the patient's acute kidney injury from renovacular hypertension, preoperative evaluation included a MRI abdomen w/wo contrast which showed a 1.4 cm right adrenal nodule with early contrast enhancement which appeared fairly avid and uniform. This nodule had been previously noted by CT scan three years prior. Previous outpatient labs showed elevated metanephrines of 543 pg/mL, which determined the adrenal nodule to be consistent with a pheochromocytoma. Subsequently, femoral popliteal bypass was postponed and the patient was started on an alpha blocker, doxazosin. Urology was consulted and right laproscopic adrenalectomy was planned. Preoperatively, patient developed chest pain due to ventricular tachycardia and NSTEMI was diagnosed by EKG. Patient then underwent a LHC which revealed severe left main 3 vessel coronary artery disease, postponing planned adrenalectomy. CABG was performed with pericardiectomy. After initial recovery, patient was discharged to in-patient rehabilitation, indefinitely delaying definitive pheochromocytoma therapy. Reference Jacques W. M. Lenders, Quan-Yang Duh, Graeme Eisenhofer, Anne-Paule Gimenez-Roqueplo, Stefan K. G. Grebe, Mohammad Hassan Murad, Mitsuhide Naruse, Karel Pacak, William F. Young, Jr, Pheochromocytoma and Paraganglioma: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 99, Issue 6, 1 June 2014, Pages 1915–1942, https://doi.org/10.1210/jc.2014-1498 Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Double Trouble: Biventricular Thrombi And Embolic Complications

<h3>Case Summary</h3> A 49 year old with peripheral vascular disease presented to his vascular surgeon with leg pain and it was found cold and pulseless. He was diagnosed with critical limb ischemia and was directly admitted to the vascular surgery. CT found a femoral artery occlusion, cardiomegaly and bi-ventricular clots. Cardiology was consulted and a TTE noted bi-ventricular thrombi and a severely dilated LV with EF=20%. Palliative care was consulted. He was taken to the OR for BKA. Post-operatively he had a PEA arrest. He was in shock and given inotropes. Invasive hemodynamics, mechanical support, and coronary angiography were limited by renal failure, vascular access and thrombi. His shock improved, but he was not a candidate for advanced therapies. Coronary angiography showed multi-vessel disease. Cardiac MR showed viability in most regions but while awaiting revascularization, he became unresponsive. CT showed R ICA occlusion, R MCA occlusion, L M1 occlusion, and R watershed infarct. He was taken for mechanical thrombectomy. MRI showed multifocal infarcts in the L MCA, left pons, and left PCA. Fluids were trialed to improve perfusion, but he became hypoxic and repeat MRI did not show any improvement. He was unresponsive. The family enrolled the patient in hospice. <h3>Discussion</h3> Our patient had no history of HFrEF. While he had risk factors, symptoms were masked by severe peripheral vascular disease. Bi-ventricular thrombi are uncommon and place the patient at risk for systemic and pulmonary embolization. Aside from anticoagulation, there is little consensus on the management of intracardiac thrombi and the risk varies significantly within published data. In severe HF, complications and inability to tolerate GDMT should warrant advanced HF consultation. Early involvement of palliative care helped guide family during end of life care. More research is needed to better inform management options in heart failure complicated by intracardiac thrombi.

The Transaxillary Approach via Prosthetic Conduit for Transcatheter Aortic Valve Replacement With the New-Generation Balloon-Expandable Valves in Patients With Severe Peripheral Artery Disease.

Background: The left subclavian artery (LSA) is an infrequently used alternative access route for patients with severe peripheral artery disease (PAD) in patients who underwent transcatheter aortic valve replacement (TAVR). We report a new endovascular approach for TAVR combining an axillary prosthetic conduit-based access technique with new-generation balloon-expandable TAVR prostheses.Methods and Results: Between January 2020 and December 2020, 251 patients underwent TAVR at the West German Heart and Vascular Center. Of these, 10 patients (3.9%) were deemed to be treated optimally by direct surgical exposure of the left or right axillary artery via a surgically adapted prosthetic conduit. All procedures were performed under general anesthesia. One procedural stroke occurred due to severe calcification of the aortic arch. No specific complications of the subclavian access site (vessel rupture, vertebral, or internal mammary ischemia) were reported. Two minor bleedings from the access site could be treated conservatively. No surgical revision was necessary.Conclusion: The axillary prosthetic conduit-based access technique using new-generation balloon-expandable valves allows safe and successful TAVR in a subgroup of patients with a high risk of procedural complications due to severe peripheral vascular disease. Considering the increasing number of patients referred for TAVR, this approach could represent an alternative for patients with limited access sites.

Successful Orbital Atherectomy of Left Main Bifurcation Lesion Using Microcatheter Protection of Nonatherectomy Wire

-Optimal PCI may be challenging with calcified left main bifurcation lesions-Orbital atherectomy is a common strategy for lesion optimization-Side branch occlusion is a feared complication of orbital atherectomy-Utilizing microcatheter wire protection can minimize occlusion risk with orbital atherectomy Corrigendum to “Successful Orbital Atherectomy of Left Main Bifurcation Lesion Using Microcatheter Protection of Nonatherectomy Wire”Journal of the Society for Cardiovascular Angiography & InterventionsVol. 1Issue 3100030PreviewFollowing publication, it was noted that several panels of Figure 1 included contouring in the IVUS images. The figure has been replaced in the original article. The revised image is shown below. Full-Text PDF Open Access Atherectomy is a tool for calcium modification, but there is an increased risk of losing the side branch in left main (LM) bifurcation lesions. Protected atherectomy using dual-1Medda M. Casilli F. Bande M. Tespili M. Protected rotational atherectomy with double-guiding catheter technique for unprotected distal left main.JACC Cardiovasc Interv. 2019; 12: e27-e29Crossref PubMed Scopus (4) Google Scholar and single-guide catheter technique2Panchal H.B. Nagabandi A. Kirtane A.J. Beohar N. Microcatheter-protected orbital atherectomy for severely calcified bifurcation coronary artery disease with single-guiding catheter technique.JACC Cardiovasc Interv. 2020; 13: e1-e3Crossref PubMed Scopus (0) Google Scholar with mechanical support has been described as a strategy to minimize side branch closure and wire damage to nontarget vessel during bifurcation atherectomy. However, single-guide catheter technique has not been reported without the use of mechanical circulatory support. We present a case of a 79-year-old man with severe, heavily calcified distal LM, proximal left anterior descending (LAD), and left circumflex artery (LCx) lesions (Fig. 1A, Supplemental Video 1) who was referred for complex percutaneous coronary intervention in the setting of reduced ejection fraction (40%), daily anginal symptoms, and viable myocardium on cardiac magnetic resonance imaging. Peripheral angiography revealed severe peripheral vascular disease prohibitive for mechanical support devices. An 8-F sheath was placed in the left femoral artery, and an 8-F XB 4.0 guide catheter was used. Intravascular ultrasound (IVUS) confirmed severe calcified stenoses in LM, LAD, and LCx (Fig. 1B, C, Supplemental Videos 2 and 3). After placement of ViperWire Advance with Flex Tip (Cardiovascular Systems Inc) in the LM-LCx for orbital atherectomy, a Runthrough wire (Terumo Interventional Systems) was placed in the LAD “protected” with a Turnpike LP microcatheter (Teleflex). Orbital atherectomy (2 runs) of the distal LM and proximal circumflex arteries was performed at low speed (Fig. 1D). The microcatheter was advanced after each pass to minimize damage. During wire exchange between the LAD and LCx, the microcatheter was removed, flushed, and checked for any damage. It was then used to “protect” the LM-LCx wire during 4 total atherectomy passes from LM into the LAD at both high and low speeds (Fig. 1E, Supplemental Video 4). After atherectomy of each vessel, the microcatheter was examined, and minor abrasions similar to those reported by Panchal et al. were noted on the catheter without any significant catheter injury.2Panchal H.B. Nagabandi A. Kirtane A.J. Beohar N. Microcatheter-protected orbital atherectomy for severely calcified bifurcation coronary artery disease with single-guiding catheter technique.JACC Cardiovasc Interv. 2020; 13: e1-e3Crossref PubMed Scopus (0) Google Scholar Therefore, the same microcatheter was used during atherectomy of both the LAD and LCx. IVUS-guided percutaneous coronary intervention using double kissing crush technique was performed with the placement of a 3.5 ​× ​18-mm drug-eluting stent in the LCx-LM and a 4.0 ​× ​18-mm drug-eluting stent in the LM-LAD with postdilation of the LM using a 5.0-mm noncompliant balloon. Final angiography and IVUS showed excellent expansion and apposition (Fig. 1F, G, Supplemental Video 5). At 3-month follow-up, the patient was doing well with resolution of anginal symptoms and normalization of left ventricular ejection fraction. Microcatheter-“protected” orbital atherectomy of LM bifurcation lesions can be successfully performed using a single 8-F guide without the need for mechanical circulatory support in patients with prohibitive comorbidities and peripheral arterial disease. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. https://www.jscai.org/cms/asset/7b35004e-dfa0-4f91-b28b-cee49b008a06/mmc1.mp4Loading ... Download .mp4 (1.04 MB) Help with .mp4 files Supplemental Video 1https://www.jscai.org/cms/asset/ffdddfda-c460-4b09-a272-55333f079168/mmc2.mp4Loading ... Download .mp4 (6.67 MB) Help with .mp4 files Supplemental Video 2https://www.jscai.org/cms/asset/ec8a523b-adc5-4933-a970-e3a33f5cfab0/mmc3.mp4Loading ... Download .mp4 (6.43 MB) Help with .mp4 files Supplemental Video 3https://www.jscai.org/cms/asset/17b83443-8235-4f23-97f7-53dfaf1a6be6/mmc4.mp4Loading ... Download .mp4 (0.95 MB) Help with .mp4 files Supplemental Video 4https://www.jscai.org/cms/asset/85d13be4-0e1e-4fb8-80db-427769cd4524/mmc5.mp4Loading ... Download .mp4 (4.2 MB) Help with .mp4 files Supplemental Video 5

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients.

O42: THE ROLE OF TOURNIQUETS IN TRANSTIBIAL AMPUTATION FOR PERIPHERAL VASCULAR DISEASE: A SYSTEMATIC REVIEW &amp; META-ANALYSIS

Abstract Introduction The use of lower limb tourniquets is traditionally discouraged in severe atherosclerotic disease. However, blood loss and increased transfusion requirements are associated with post-operative morbidity in patients undergoing major lower limb amputation. The aim of this systematic review is to summarise and pool the available data to determine the impact of tourniquet application when performing trans-tibial amputation for peripheral vascular disease. Method This systematic review was conducted according to PRISMA guidelines. A systematic search of Medline, Embase and Cochrane Library was undertaken for articles which compared the use of a tourniquet versus no tourniquet in patients undergoing trans-tibial amputation for peripheral vascular disease. The main outcomes included intra-operative blood loss, post-operative transfusion requirement, need for revision surgery and 30-day mortality. Result Four studies met the inclusion criteria for quantitative analysis with a total of 267 patients. A tourniquet was used in 130 patients. Both groups were matched for age, gender, co-morbidities and pre-operative haemoglobin. In patients undergoing trans-tibial amputation, tourniquets were associated with significantly lower intra-operative blood loss (Mean difference= -147.6mls; P=0.03) and lower transfusion requirements (pooled odds ratio (OR), 0.12, p=0.03). The need for stump revision (OR, 0.7; p=0.48), proceeding to transfemoral amputation within 30 days (OR, 0.67; p=0.25) and 30-day mortality (OR, 0.65; p=0.41) all favoured tourniquet use but the differences were not found to be significant. Conclusion Tourniquets can reduce intra-operative blood loss and transfusion requirements in patients undergoing trans-tibial amputation without increasing ischaemic complications and need for revision surgery. Take-home message Tourniquets are safe to use in trans-tibial amputation for severe peripheral vascular disease and can reduce intra-operative blood loss without increasing ischaemic complications.

Case Report: Novel SAVI-Causing Variants in STING1 Expand the Clinical Disease Spectrum and Suggest a Refined Model of STING Activation

Gain-of-function mutations in STING1 cause the monogenic interferonopathy, SAVI, which presents with early-onset systemic inflammation, cold-induced vasculopathy and/or interstitial lung disease. We identified 5 patients (3 kindreds) with predominantly peripheral vascular disease who harbor 3 novel STING1 variants, p.H72N, p.F153V, and p.G158A. The latter two were predicted by a previous cryo-EM structure model to cause STING autoactivation. The p.H72N variant in exon 3, however, is the first SAVI-causing variant in the transmembrane linker region. Mutations of p.H72 into either charged residues or hydrophobic residues all led to dramatic loss of cGAMP response, while amino acid changes to residues with polar side chains were able to maintain the wild type status. Structural modeling of these novel mutations suggests a reconciled model of STING activation, which indicates that STING dimers can oligomerize in both open and closed states which would obliviate a high-energy 180° rotation of the ligand-binding head for STING activation, thus refining existing models of STING activation. Quantitative comparison showed that an overall lower autoactivating potential of the disease-causing mutations was associated with less severe lung disease, more severe peripheral vascular disease and the absence of a robust interferon signature in whole blood. Our findings are important in understanding genotype-phenotype correlation, designing targeted STING inhibitors and in dissecting differentially activated pathways downstream of different STING mutations.

Immediate ECMO Initiation Leads to Graft Recovery in Delayed Graft Failure after Heart Transplant

<h3>Introduction</h3> Graft failure is a leading cause of thirty-day mortality for heart transplant (HTx). Primary graft dysfunction, defined as occurring within 24 hours of transplantation, is the most frequent cause of graft failure. We present a rare case of delayed graft failure, which occurred on postoperative day (POD) 9, of unknown cause successfully recovered by immediate veno-arterial extracorporeal membrane oxygenation (VA-ECMO) initiation and subsequent biventricular assist device (BiVAD) support. <h3>Case Report</h3> A 55-year-old male with end stage heart failure from ischemic cardiomyopathy and severe peripheral vascular disease (PVD) underwent successful HTx surgery. On POD 6, he was transferred out of the ICU in stable condition. His POD 6 transthoracic echocardiogram (TTE) showed left ventricular ejection fraction (LVEF) of 60% with mild-moderately reduced right ventricular (RV) function. On POD 9, the patient went into sudden cardiac arrest, with return of spontaneous circulation after cardiopulmonary resuscitation. VA-ECMO was initiated immediately afterward, with right axillary arterial percutaneous cannulation due to severe PVD. A subsequent TTE showed LVEF of 5%, and a nearly akinetic RV, concerning for delayed graft failure. The patient was transitioned to extracorporeal BiVAD support on POD 21. A biopsy taken POD 21 showed non-infective myocarditis with no evidence of rejection. Prior to BiVAD explant (POD 78), TTE showed improved heart function: LVEF of 45% and only moderately reduced RV function. The BiVAD was explanted after 63 days of support. He was discharged 34 days after BiVAD explant; the presumed cause of delayed graft failure was secondary to residual pulmonary hypertension post-HTx. <h3>Summary</h3> In a case of rare delayed graft failure of unknown cause, immediate VA-ECMO initiation, followed by proper MCS management successfully rescued graft function.

Abdominal Pain and Diarrhea in Peptic Ulcer Disease

Question: A 47-year-old woman with chronic malnutrition presented to hospital with a 3-day history of worsening abdominal pain, diarrhea, intermittent hematochezia, and anorexia. She had presented 2 months earlier with melena and was found to have a large cratered gastric body ulcer on endoscopy (Figure A). Biopsies of the ulcer did not show malignancy. She was on long-term 15 mg/day prednisolone and methotrexate for Takayasu arteritis and had severe peripheral vascular disease. She was a heavy smoker but denied any recent nonsteroidal antiinflammatory use.

Variations in knee range of motion during repeat knee extension with an amputated lower leg at different contraction rhythms over 8 consecutive days in a patient with severe diabetic neuropathy: A clinical study

Background: This clinical study sought to understand the knee range of motion (KROM) in an amputated stump during repeat voluntary knee extension with or without a 0.5 kg weight in the acute/early phase after amputation can vary between different target knee extension rhythm frequency (KER) levels in the amputated lower leg of a patient with severe diabetic sensory disorder and leg ischemia. Case Presentation: A 51-year-old male patient with severe diabetic neuropathy had a right lower leg amputation due to necrosis and ulcer lesion following a burn injury to the first toes and severe ischemic peripheral vascular disease. In a sitting position with the base of the foot of the non-amputated left leg on the ground, he performed repeat knee extension of the resected stump (knee active extension and passive flexion without a target KROM) for 1 min with both self-controlled free KER and different target KERs (30, 40, 50, 60, and 80 contractions per minute [cpm] using a metronome), with or without a 0.5 kg weight placed on the resected stump over 8 consecutive days. The KROM was measured using a goniometer placed between the resected stump and the thigh muscle with a continuous data acquisition system. The mean values achieved for KER, KROM, and angle rate during a 1 min session was determined during each daily session, and consecutively average values over sessions on 8 consecutive days was also evaluated. The achieved mean KER at all target KERs corresponded closely with the target KER. The average KROM was approximately 60 degrees over a range of targets between 30 and 60 cpm, but the value was lower at approximately 50 degrees at 80 cpm. The angle rate increased consistently with the increase from a target of 30 to 60 cpm, but it was reduced at 80 cpm. The mean KROM was inversely related (r=-0.390, P&lt;0.01, n=40) to the mean KER without the weight, but not significantly (r=-0.256, P=ns, n=40) with the 0.5 kg weight. The achieved KER in the self-controlled free trial with or without the 0.5 kg weight might increase with an increase in sessions over 8 days with a range between approximately 30 and 60 cpm. Conclusion: The present case study showed that a higher contraction frequency may limit KROM determined below 60 cpm because of the reduced angle rate in an amputated lower leg. A low and moderate KER below 60 cpm may be appropriate to maintain KROM with a stable angle rate. Furthermore, voluntary KER with free self-controlled rhythm may increase over the course of multiple sessions as familiarity improves with kicking the amputated limb and generating a potential improvement in performance/ability effect with consecutive leg exercise with no use of a prothesis such as in the early/acute phase post-amputation using audible biofeedback.

Off-pump HeartMate II Exchange in a Patient with Severe Lower Extremity Peripheral Artery Disease: A Case Report

Thrombosis of left ventricular assist device (LVAD) pumps is a serious complication that often requires exchange of the device. A 66-year-old man with severe peripheral vascular disease presented with pump thrombosis of the HeartMate II (HMII) LVAD 1.5 years after implantation. The HMII was exchanged to another HMII through a subcostal incision and without the use of cardiopulmonary bypass. For safety, the patient was prepared for cardiopulmonary bypass by exposing the right subclavian artery and insertion of a 5 FR cannula in the left common femoral vein. The pump was exchanged through a subcostal incision made over the LVAD pump pocket perpendicular to the costal margin. After deairing the pump and graft, LVAD support was resumed, postoperative course was uneventful, and the patient was discharged from the hospital four days later. Re-thrombosis, stroke, and right heart failure are frequent complications after LVAD exchange. Exchange through a subcostal incision with cardiopulmonary bypass backup appears to be safe.

Left brachial artery: one more way to percutaneous insertion of IMPELLA 2.5L circulatory support for high-risk percutaneous coronary intervention - a case report.

BackgroundPercutaneous circulatory support allows the performance of coronary interventions in ever more complex anatomic and clinical situations. The large-bore systems currently available need a suitable vascular calibre to be inserted restricting percutaneous access mainly to the common femoral artery.Case summaryWe present the case of a 64-year-old man, admitted with an acute coronary syndrome and congestive heart failure, due to triple-vessel coronary artery disease with left main involvement and left ventricular dysfunction. He was successfully treated with percutaneous coronary intervention (PCI) supported through an IMPELLA 2.5L circulatory system. Concomitant severe and diffuse peripheral vascular disease did not allow femoral insertion of the circulatory support which was therefore successfully introduced through a left brachial percutaneous approach.DiscussionTo the best of our knowledge, this is the first report of a brachial, percutaneous placement of the IMPELLA 2.5L system to support a high-risk PCI procedure. In appropriately selected patients, this approach could be an option when common vascular accesses are not available.

Stroke and Thromboprophylaxis in the Era of COVID-19

Stroke and Thromboprophylaxis in the Era of COVID-19

S2986 Ischemic Gastropathy in a Patient With Severe Atherosclerotic Disease Treated With Mesenteric Revascularization

INTRODUCTION: Gastric ischemia is rare due to the rich vascular supply to the stomach. This arterial supply is achieved through five major direct sources, which include the right and left gastric, the right and left gastroepiploic, and the short gastric arteries. Upper GI bleeding caused by Ischemic gastropathy from mesenteric ischemia is rare, however isolated gastric ischemia resulting in bleeding is even less common with only few cases reported in literature. We report a case of a 71-year-old man with history of peripheral vascular disease who presented to the hospital with upper GI bleed. CASE DESCRIPTION/METHODS: A 71-year-old man with history of severe peripheral vascular disease, hypertension and hyperlipidemia presents to the hospital with complaints of abdominal pain worsened by food ingestion and melena. On presentation Hb was 7.4 mg/dL, which dropped to 6.0 mg/dl. CT scan of the abdomen showed diffuse atherosclerosis of the celiac, superior mesenteric (SMA) and inferior mesenteric arteries. Patient underwent upper endoscopy which showed multiple ulcers through the body of the stomach as well as areas of pale gastric mucosa raising suspicion for ischemic gastropathy. Patient underwent aortogram which showed celiac artery occlusion and severe stenosis of the SMA. Subsequent stenting of the SMA resulted in the resolution of patient’s symptoms. Repeat EGD performed 8 weeks later showed healing of the ulcers. DISCUSSION: Ischemic gastropathy is a rare cause of upper GI bleeding due to the rich blood supply of the stomach. The definitive treatment is revascularization. It should be suspected in patients with risk factors that presents with upper GI bleeding and endoscopic findings of multiple ulcers and pale gastric mucosa. Few cases showed clinical improvement with revascularization of the superior mesenteric artery. Our patient is a rare case of isolated ischemic gastropathy with complete occlusion of the celiac artery who responded to SMA revascularization.Figure 1.: Endoscopy showing multiple ulcers.Figure 2.: Patchy areas of pale mucosa observed during first EGD.Figure 3.: Last endoscopy showing appropriate ulcer healing.