Successful Endovascular Revascularization Research Articles

Endovascular Recanalization in Patients With Vertebral Artery Stump Syndrome: A Single-Center Experience.

To evaluate the feasibility, success rate, and safety of endovascular revascularization of patients with vertebral artery stump syndrome (VASS). This single-center retrospective study analyzed clinical and imaging data from consecutive patients with VASS who underwent endovascular recanalization from January 2020 until June 2023. Our study enrolled 30 patients [mean age 69 (range 51-84) years; 26 men]. The rate of successful technical revascularization was 96.7% (n = 29), and the rate of complications was 3.3% (n = 1). At the 6-month follow-up, the patients with successful endovascular revascularization of VASS did not have any neurological symptoms, and computed tomography angiography showed 3/29 (10.3%) re-occlusions and 4/29 (13.8%) restenosis of the stent, which was confirmed by digital subtraction angiography. Endovascular recanalization in patients with VASS is feasible in selected patients and has a high procedural success rate and low rate of complications. A large, multicenter, randomized study is warranted to confirm these findings.

Patient and procedural characteristics of successful endovascular procedures in the BEST-CLI Trial and their relationship to major adverse limb events

Abstract Background The Best Endovascular versus Best Surgical Therapy in Patients with Chronic Limb Threatening Ischemia (CLTI) (BEST-CLI) trial randomized 1830 subjects with chronic limb threatening ischemia (CLTI) to endovascular or surgical bypass revascularization. Major adverse limb events (MALE) were higher after endovascular revascularization compared to bypass in the cohort with bypass using adequate single segment great saphenous vein. However, 15% of endovascular procedures had a major endpoint due to lack of technical success of the index procedure. Purpose To assess the factors related to a MALE in subjects in the BEST-CLI trial with an initial endovascular procedure that was technically successful. Methods All patients with a technically successful endovascular procedure (defined as a residual stenosis < 50% in the superficial femoral, popliteal, and/ or tibial arteries with in-line flow to the foot) were included. MALE was defined as above ankle amputation of the index limb or a major index-limb reintervention (new bypass, interposition graft revision, thrombectomy, or thrombolysis). Patient, procedure, and limb characteristics at the time of the index procedure were compared to the risk of MALE over an average 2.7 years follow-up. Characteristics were compared with the Kruskal-Wallis or Chi-square tests as appropriate. Results Of 923 patients having endovascular therapy as the index revascularization, 773 (84%) had a technically successful procedure. The cause of failure in 122 (82%) of unsuccessful procedures was the inability to cross the lesion with a wire. Significant patient factors associated with MALE included younger age (64 vs 68 years, p<0.0001), current smoking (44% vs 33%, p=0.004), and end-stage renal disease (17% vs 10%, p=0.013). Diabetes mellitus was not associated with MALE (74% vs 68%, p=0.08). Significant limb characteristics associated with MALE included lesions treated in the superficial femoral (SFA) or above knee popliteal artery (87% vs 81%, p=0.042), length of lesion in the SFA or above knee popliteal artery (201 cm vs 172 cm, p=0.02), use of atherectomy and bare-metal stent (10% vs 5%, p=0.01), and total procedure time (172 vs 155 min, p=0.002). Lesions treated in the below-knee popliteal artery or tibial arteries (62% vs 62%, p=0.93) or lesion length in this region (134 vs 144 cm, p=0.70) were not related to the risk of MALE. Conclusions The risk of MALE after successful endovascular revascularization for CLTI was increased with younger age, current smoking, end-stage renal disease, longer lesion length, treatment of the SFA to above knee popliteal arteries, and treatment with atherectomy with bare-metal stenting. Treatment of below knee lesions were not associated with MALE. These results indicate the importance of both modifiable and non-modifiable patient factors as well as the anatomic location of disease in determining limb outcomes in CLTI.

Lesion Localization and Limb Outcomes in Elderly Patients with and Without Type 2 Diabetes Mellitus Who Undergo Atherectomy-Assisted Endovascular Revascularization due to Symptomatic Peripheral Artery Disease.

Background/Objectives: Type 2 diabetes mellitus (T2DM) represents a major risk factor for peripheral artery disease (PAD). We aimed to evaluate the impact of T2DM on lesion localization and complexity, clinical presentation by Rutherford categories, and limb outcomes in elderly patients with symptomatic PAD undergoing endovascular revascularization. Methods: Five hundred consecutive patients with symptomatic infra-inguinal PAD who underwent rotational atherectomy-assisted endovascular revascularization were included. PAD clinical presentation and lesion localization were recorded. The primary endpoints were clinically driven target lesion revascularization (CD-TLR) and major amputation rates during follow-up. Results: Overall, 245/500 (49.0%) patients had T2DM, whereas 179 (35.8%) presented with lifestyle limiting claudication and 321 (64.2%) with critical limb-threatening ischemia (CLTI). Median age was 78.0 (IQR = 70.0-84.0) years, and 201 (40.2%) patients were female. The presence of T2DM was significantly more frequent in patients with CLTI vs. those with claudication (58.6 vs. 31.8%; p < 0.001). Furthermore, the percentage of patients with below-the-knee (BTK) lesions was significantly higher in patients with vs. without T2DM (40.7 vs. 27.5%, p = 0.0002). During median follow-up of 21.9 (IQR = 12.8-28.8) months, CD-TLR rates were similar in patients with vs. without T2DM (HR = 1.2, 95%CI = 0.8-2.0, p = 0.39). However, patients with T2DM had a ~5.5-fold increased risk for major above-the-ankle amputation (HR = 5.5, 95%CI = 1.6-19.0, p = 0.007). After adjustment for age, gender, lesion complexity, and calcification, T2DM remained predictive for major amputation (p = 0.04). Conclusions: T2DM is more frequently associated with CLTI, BTK-PAD, and amputations despite successful endovascular revascularization. More stringent surveillance of patients with PAD and T2DM is warranted to prevent atherosclerosis-related complications.

Long-Term Adverse Limb Events After Femoral Artery Endovascular Revascularization: The Boston FAROUT Study

Background: Patient, lesion, and procedural characteristics may impact the long-term risks of adverse limb outcomes differently after successful endovascular revascularization for lower extremity peripheral artery disease. The study objective was to assess the relationships of patient, lesion, and procedural characteristics to the subsequent risk of major and minor adverse limb events over the decade after successful endovascular revascularization of the superficial femoral artery for chronic limb-threatening ischemia (CLTI) or lifestyle-limiting claudication. MethodsA retrospective cohort of patients who underwent endovascular revascularization between 2003-2011 were followed for a median of 9.3 (IQR, 6.8-11.1) years. Hazard ratios (HR) and 95% CI from Cox proportional hazards models assessed the risk of major adverse limb events (MALE) (major amputation, bypass, or thrombolysis) or minor revascularization, MALE alone, and minor revascularization alone. ResultsThere were 232 index limb revascularizations in 185 patients. Longer lesion length was associated with a higher risk of MALE or minor revascularization (HR, 2.09; 95% CI, 1.22-3.60) and minor revascularization alone (HR, 2.53; 95% CI, 1.39-4.61). Current smoking was linked with minor revascularization (HR, 3.83; 95% CI, 1.54-9.56). CLTI was associated with MALE or minor revascularization (HR, 1.89; 95% CI, 1.09-3.29), and MALE alone (HR, 7.43; 95% CI, 3.11-17.79). Black race/ethnicity (HR, 4.74; 95% CI, 1.51-14.9) and low-density lipoprotein >100 mg/dL (HR, 2.76; 95% CI, 1.20-6.35) were linked to MALE alone. ConclusionsFactors related to MALE differed from those related to minor revascularization. Lesion length and smoking were linked to minor revascularization, whereas CLTI, Black race/ethnicity, and elevated low-density lipoprotein were linked to MALE.

Can wound blush be used as an indicator for termination of endovascular procedures in chronic limb-threatening ischemia patients?

Predicting the outcomes of endovascular revascularization of chronic limb-threatening ischemia (CLTI) patients with foot wounds can be challenging. Angiographic wound blush (WB) assessment has been found to be a helpful tool to assess wound perfusion. The aim of this study is to evaluate WB during endovascular revascularization of CLTI patients and its effects on treatment outcomes. This prospective study included all CLTI patients with foot wounds who underwent successful endovascular revascularization of infrainguinal arterial disease between 2019 and 2021. Patients were grouped according to the WB status into positive WB (group A) and negative WB (group B). Both groups were compared for demographics, comorbidities, clinical picture, and 12-month limb-based patency (LBP) and amputation-free survival (AFS) rates. The study included 69 patients of Rutherford classes 5 (46.4%) and 6 (53.6%), with the main arterial lesion located at the femoropopliteal (58%) or infrapopliteal (42%) segments. Completion angiography showed positive WB in 38 (55.1%) patients and negative WB in 31 (44.9%) patients. Both groups were comparable regarding patient presentation, site of the main arterial lesion, and distribution of foot lesions in relation to the feeding artery. The overall 12-month LBP and AFS rates were 21.7% and 39.1%, respectively, with significantly better rates in group A than in group B (LBP, 31.6% vs 9.7%, p = 0.001 and AFS, 54.1% vs 22.2%, p = 0.006, respectively). Successful angiosome-based direct flow to the foot was achieved in 38 patients (55.1%), resulting in significantly better 12-month AFS rates than those with indirect revascularization (54.8% vs 26.3%, p = 0.036, respectively), despite the comparable 12-LBP rates between the direct and indirect revascularization groups (29% vs 15.8%, p = 0.133, respectively). Multivariate logistic regression analysis identified smoking as a significant predictor of a major amputation, whereas positive WB and successful direct revascularization were significant predictors of limb salvage. WB can serve as a predictor for AFS and LBP during endovascular revascularization of CLTI patients with foot wounds. A positive WB may guide the decision to conclude an endovascular procedure, potentially avoiding unnecessary complicated maneuvers to recanalize more vessels. Conversely, a negative WB may suggest the need for further revascularization attempts to augment wound perfusion and healing.

Abstract TP206: Transcranial Doppler Markers of Increased Microvascular Resistance After Successful Endovascular Revascularization Are Associated With Larger Infarct Volumes

Background: Markers of increased microvascular resistance on Transcranial Doppler (TCD) obtained shortly after successful endovascular therapy (EVT) in patients with large-vessel occlusion (LVO) stroke have been associated with unfavorable outcomes. We aim to investigate whether post-EVT pulsatility index (PI) correlates with final infarct volume in this population. Methods: We analyzed consecutive anterior circulation LVO patients who underwent successful EVT (mTICI 2c-3) from 2012 to 2022. Patients with available TCD within 48 hours of EVT and brain MRI during admission were included. The TCD-derived PI was obtained from the ipsilateral middle cerebral artery. The ABC/2 method was used to estimate the final infarct volume in mL on MRI diffusion-weighted imaging. Pearson correlation and adjusted linear regression analysis were used to investigate the relationship between post-EVT PI and final infarct volume. Linear regression analysis was adjusted for age, NIHSS, and ASPECTS. Results: Out of 155 LVO patients with successful EVT during the study period, 40 were included in the analysis (mean age, 69 ± 16.7 years; 57% female; median NIHSS 15 (IQR 10); and median ASPECTS 9 (IQR, 2)). The median time from EVT to TCD and EVT to MRI was 21 hours (IQR, 17 hours) and 41 hours (IQR, 33 hours), respectively. Post EVT PI displayed a positive moderate correlation with final infarct volume (r=0.39, p&lt;0.01; Figure 1). Larger PI values were independently associated with larger infarct volumes (β = 42.2 mL, 95% CI 37.0 - 47.5 mL). Conclusion: TCD-derived PI shortly after EVT correlated with final infarct volume in successfully revascularized LVO patients. TCD may serve as a valuable tool to identify those at risk for infarct progression and reveal potential therapeutic targets to maximize EVT benefit in this population.

Exercise therapy results of postoperativ treated critical iliac artery stenosis (TASC II A and B) patients who were infected with the Covid 19

Introduction: Adequate individual physical activity after COVID 19 infection as a inevitable part of postoperative therapy of surgically treated vascular and endovascular patients witch still remains a scientific unexplored international neglected secret. General post-covid symptomatology is increasingly present in patients with surgical or endovascular procedures on the iliac segment in the form of a manifestation of various complaints that can affect the very accessibility of the choice of treatment according to the TASC II guidelines, but also affect physical activity and quality of life. Besides the medicament treatment, the management of moderate intensity exercise therapy and future consistency of self-controlled exercise after surgical and endovascular after treatment in iliac critic stenosis with other asymptomatic systemic atherosclerosis can be important factor to support and improve benefits of surgical and endovascular treatment outcome in variable symptomatology of POSTCOVID 19 patients treated classical surgical and endovascular. Goals: The focus is on priority of investigation of remodeling the pattern of cultural smoking behavior and increasing the dynamic of physical activity trying to prevent and avoid potential risk of sudden death, myocardial infarction, stroke graft (stent) occlusion, and cardiovascular mortality in patients with POSTCOVID 19 symptomatology in which is besides other asymptomatic systemic atherosclerosis is the main disease critical iliac artery stenosis (TASC II A and B). Scientifically unproven that sometimes can be associated with poor outcome of surgical intervention the which are in deficit with scientific studies to confirm these scientific observations. Second goals are to investigate the potential possibility of POST COVID 19 symptomatology associated with the success of classic surgical bypass or endovascular intervention and the possibility of reflection on physical activity after vascular intervention. Also the improving and secure the quality of life after successful surgical bypass and endovascular revascularization treatment with influence on primary iliac (TASC II A and B) vascular intervention potency one of main goals as well suppress permanent or permanent consequences of the Covid 19 virus during therapeutic surgical or endovascular procedures of the iliac segment (TASC II A and B) Traditional food as well wrong choice of diet and continuous fight with nicotinism is still remains generally main health threat. Subjects and Methods: 266 Symptomatic post COVID 19 Patients with were observed during 3 years (134 patients with surgical dacron reconstruction and 132 with endovascular treatmant of short segment critical iliac artery stenosis) Moderate interval Intensity Training with Short Interval Repetitions on standard treadmill procedure. Results: The connection of the outcome of surgical and endovascular treatment with post and long covid 19 symptomatology is possible and has a significant impact on the quality of the continuation of physical medication therapy. Difference between the surgical and endovascular groups was observed after the implementation of the treatment as well as factors affecting the outcome of therapy. the outcome is devastating with the prevention of the risk factor of nicotism as well as with the lack of physical activity in some groups. Conclusion: Primary potency after Three years of Endovascular procedure and Dacron bypass Revascularization, has shown as successful with support of supervised exercise training in POSTCOVID 19 patients. Nicotiism still remains highly potency outcome threat when supporting exercise therapy. Also, future and recent studies on this topic should expand their understanding of the effect of the COVID 19 virus on the body in this patients, as well as improving the quality of life in order to improve the patency of bypass or endovascular intervention on the arterial iliac segment.

Percutaneous Deep Venous Arterialization for Limb Salvage in No Option Patients with Chronic Limb-Threatening Ischemia.

An endovascular approach is often considered the first line treatment option for lower limb chronic limb-threatening ischemia (CLTI), which is defined by the presence of ischemic rest pain and severe tissue loss, such as ulcers or gangrene. Although the technical success rate of endovascular revascularization is high, in specific patients with advanced infrapopliteal disease and the absence of run-off tibial vessels, the so-called 'desert foot', the chance of successful endovascular revascularization is minimal. In order to avoid primary amputation, several treatment options are currently being investigated, including gene therapy and deep venous arterialization. This review focuses on the percutaneous deep venous arterialization technique as a promising, minimally invasive treatment option for limb salvage in CLTI patients presenting with a 'desert foot'.

Differences between Lower Extremity Arterial Occlusion vs. Stenosis and Predictors of Successful Endovascular Interventions.

Background and Objectives: In patients with peripheral artery disease, there is insufficient understanding of characteristics that predict successful revascularization of the lower extremity (LE) chronic total occlusions (CTOs) and baseline differences in demographic, clinical, and angiographic characteristics in patients with LE CTO vs. non-CTO. We aim to explore these differences and predictors of successful revascularization among CTO patients. Materials and Methods: Two vascular centers enrolled LE-CTO patients who underwent endovascular revascularization. Data on demographics, clinical, angiographic, and interventional characteristics were collected. LE non-CTO arterial stenosis patients were compared. A total of 256 patients with LE revascularization procedures were studied; among them, 120 had CTOs and 136 had LE stenosis but no CTOs. Results: Aspirin use (Odds ratio, OR: 3.43; CI 1.32-8.88; p = 0.011) was a positive predictor whereas a history of malignancy (OR: 0.27; CI 0.09-0.80; p = 0.018) was a negative predictor of successful crossing in the CTO group. The CTO group had a higher history of myocardial infarction (29.2 vs. 18.3%, p = 0.05), end-stage renal disease (19.2 vs. 9.6%, p = 0.03), and chronic limb-threatening ischemia as the reason for revascularization (64.2 vs. 22.8%, p < 0.001). They were more likely to have advanced TransAtlantic Inter-Society Consensus (TASC) stages, multi-vessel revascularization procedures, longer lesions, and urgent treatment. Conclusions: The use of aspirin is a positive predictor whereas a history of malignancy is a negative predictor for successful crossing in CTO lesions. Additionally, LE-CTO patients have a higher incidence of comorbidities, which is expected given their higher disease burden. Successful endovascular re-vascularization can be associated with baseline clinical variables.

Abstract 16108: Impact of Early Intervention on Quality of Life Outcomes in Peripheral Artery Disease Patients With Chronic Total Occlusion Lesions: Results From the PORTRAIT Registry

Background: Peripheral artery disease (PAD) is associated with functional impairment, decreased quality of life, and increased risk of cardiovascular events and mortality. Chronic total occlusion (CTO) lesions occur in up to 40% of PAD patients and pose a challenge for successful endovascular revascularization. We aim to evaluate the baseline characteristics, presentations, procedural outcomes, and quality of life (QOL) outcomes of CTO lesions in PAD compared to non-CTO lesions and the interaction with invasive therapy. Methods: The PORTRAIT registry is a prospective, multicenter, international study that enrolled patients with new or worsening claudication symptoms and an abnormal resting or post-exercise ankle brachial index. Patients with CTO lesions were compared to those without CTO lesions and divided into those who received early invasive treatment (revascularization within three months of enrollment) or noninvasive treatment with medical management. Quality of life outcomes were evaluated using the Peripheral Artery Questionnaire (PAQ) at baseline and during follow-up at 3, 6, and 12 months. Results: A total of 581 matched patients were identified, of which 39% had CTOs and 61% did not. Of the patients with CTOs, 31% underwent early invasive treatment and 69% were noninvasively managed. Patients with CTOs were more likely to present with higher Rutherford classification. The PAQ Summary Score was similar at baseline in patients with CTOs compared to those without CTOs. At 12-month follow-up, early invasive treatment resulted in higher PAQ summary scores in the non CTO arm (82.48 ± 22.79 vs. 67.83 ± 27.00, P&lt;0.001). In the CTO arm, while PAQ summary score was higher at 3 and 6 months in the early invasive arm, the difference was not significant at 12 months (76.18 ± 25.16 vs. 70.60 ± 24.24, P=0.14) Conclusions: Patients with CTO lesions present with higher Rutherford classification than their non-CTO counterparts and both have similar PAQ summary scores at presentation. Early invasive treatment for CTO and non-CTO lesions in PAD patients is associated with significant improvements in quality-of-life outcomes.

Endovascular revascularization of chronically occluded common carotid artery for symptomatic cerebral hypoperfusion.

Endovascular recanalization is increasingly being utilized in symptomatic patients with chronically occluded carotid arteries.1 In carefully selected patients, endovascular recanalization has shown to lower the risk of ischemic events when compared to medical management alone.1 However, successful endovascular revascularization is technically challenging and not without risk.1, 2 In this video, we demonstrate a case of a 64-year-old woman who presented with recurrent transient ischemic attacks. On imaging she was found to have a chronic total occlusion of the common carotid artery from the arch. After obtaining informed consent, the patient underwent a successful endovascular recanalization and stenting of a chronically occluded left common carotid artery with aid from an intravascular guided re-entry catheter. Post operatively the patient developed a neck hematoma which improved and she returned to her neurological baseline. She reported no further symptoms on her three month follow up.

Transcranial Doppler After Successful Endovascular Revascularization and Hospitalization Outcomes

Background Almost half of large‐vessel occlusion strokes have unfavorable outcomes despite successful endovascular therapy. We aim to investigate whether postrevascularization cerebral hemodynamics, determined by transcranial Doppler (TCD), associate with hospitalization outcomes in this population. Methods The current observational cohort study analyzed 155 patients with successfully revascularized anterior circulation large‐vessel occlusion stroke (mean age, 68.3±15.4 years; 55% women) who had TCD within 48 hours from endovascular therapy. TCD parameters (mean flow velocity, peak systolic velocity, and pulsatility index) were recorded at the ipsilateral middle cerebral artery, and blood flow signals were categorized using the Thrombolysis in Brain Ischemia grades into normal (grade 5), stenotic (grade 4), or dampened (grade ≤3). Hospitalization outcomes comprised favorable discharge modified Rankin Scale score (0–2), favorable discharge destination (home or acute inpatient rehabilitation), and in‐hospital mortality. Logistic regression models adjusted for age, initial National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT [Computed Tomography] Score were fit to determine TCD findings in association with study outcomes. Results Abnormal TCD‐derived blood flow was found in 54 (35%) cases, including 35 (23%) with Thrombolysis in Brain Ischemia grade 4 and 19 (12%) with Thrombolysis in Brain Ischemia grade ≤3. Overall, 31% had favorable discharge modified Rankin Scale score, 65% had favorable destination, and 14% died. Thrombolysis in Brain Ischemia grade ≤3 was associated with lower likelihood of both favorable discharge modified Rankin Scale score (adjusted odds ratio [OR], 0.09 [95% CI, 0.01–0.81]) and favorable destination (adjusted OR, 0.22 [95% CI, 0.07–0.71]). Mean flow velocity and peak systolic velocity were not associated with study outcomes. Conversely, increased pulsatility index was inversely associated with favorable destination (adjusted OR, 0.34 [95% CI, 0.13–0.87]). Conclusions TCD after successful endovascular therapy identified abnormal blood flow in one‐third of cases. Dampened flow and markers of increased microvascular resistance were associated with unfavorable hospitalization outcomes. TCD could provide valuable prognostic information in this population and identify potential therapeutic targets.

Specialty Balloons for Vessel Preparation During Infrainguinal Endovascular Revascularization Procedures: A Review of Literature.

Balloon angioplasty with/without utilizing drug eluting technology or stenting constitutes the treatment of choice for a significant percentage of patients with peripheral artery disease requiring an intervention. However, in cases of diffuse disease and plaque complexity, angioplasty may lead to dissection, recoil, and/or early restenosis, making vessel preparation a key component for successful and durable endovascular revascularization outcome. This review of literature aims to present contemporary data for several commercially available specialty balloons that have been designed to minimize the arterial wall stress of conventional balloon angioplasty and facilitate technical success, as well as long-term patency.

Optimal strategy for antiplatelet therapy after endovascular revascularization in patients with lower extremity artery disease

Abstract Background The duration of antiplatelet therapy after endovascular revascularization in patients with lower extremity artery disease (LEAD) has not been well established. This study aimed to evaluate the clinical outcome according to the duration of dual antiplatelet therapy (DAPT) in real practice. Methods From April 2009 to June 2019, 376 patients with LEAD underwent successful endovascular revascularization. After the procedure, the received single antiplatelet therapy (SAPT) or DAPT of various durations were classified into two groups (SAPT or DAPT &amp;lt;6 months vs. DAPT ≥6 months). The primary outcomes were major adverse cardiovascular events (MACEs) and major adverse limb events (MALEs). The safety outcome was moderate-to-severe bleeding according to the Global Use of Strategies to Open Occluded Arteries (GUSTO) criteria. Results Over the 40-month follow-up period, MACE occurred less frequently in the DAPT ≥6 months group than that in the SAPT or DAPT &amp;lt;6 months group (12.4% vs. 23.8%; hazard ratio [HR]: 0.56; 95% confidence interval [CI]: 0.35–0.89; p=0.014) after inverse probability-weighted adjustment and propensity-score matching analysis (HR: 0.55, 95% CI; 0.30–0.99, p=0.048). The incidence of MALE did not show significant difference between the two groups (DAPT ≥6 months group: 17.1% vs. SAPT or DAPT &amp;lt;6 months group: 13.1%; HR: 1.05; 95% CI: 0.62–1.78; p=0.846). A significant difference between the DAPT ≥6 months group and the SAPT or DAPT &amp;lt;6 months group was not observed regarding the incidence of moderate-to-severe GUSTO bleeding. Conclusions In patients with LEAD, DAPT for ≥6 months after endovascular revascularization was associated with a lower incidence of MACE. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): National Research Foundation of Korea (NRF) grant funded by the government of Korea (MSIT) (No. 2019R1G1A1100442).

Toward a Better Understanding of Muscle Microvascular Perfusion During Exercise in Patients With Peripheral Artery Disease: The Effect of Lower-Limb Revascularization

Purpose: Leg muscle microvascular blood flow (perfusion) is impaired in response to maximal exercise in patients with peripheral artery disease (PAD); however, during submaximal exercise, microvascular perfusion is maintained due to a greater increase in microvascular blood volume compared with that seen in healthy adults. It is unclear whether this submaximal exercise response reflects a microvascular impairment, or whether it is a compensatory response for the limited conduit artery flow in PAD. Therefore, to clarify the role of conduit artery blood flow, we compared whole-limb blood flow and skeletal muscle microvascular perfusion responses with exercise in patients with PAD (n=9; 60±7 years) prior to, and following, lower-limb endovascular revascularization. Materials and Methods: Microvascular perfusion (microvascular volume × flow velocity) of the medial gastrocnemius muscle was measured before and immediately after a 5 minute bout of submaximal intermittent isometric plantar-flexion exercise using contrast-enhanced ultrasound imaging. Exercise contraction-by-contraction whole-leg blood flow and vascular conductance were measured using strain-gauge plethysmography. Results: With revascularization there was a significant increase in whole-leg blood flow and conductance during exercise (p<0.05). Exercise-induced muscle microvascular perfusion response did not change with revascularization (pre-revascularization: 3.19±2.32; post-revascularization: 3.89±1.67 aU.s−1; p=0.38). However, the parameters that determine microvascular perfusion changed, with a reduction in the microvascular volume response to exercise (pre-revascularization: 6.76±3.56; post-revascularization: 2.42±0.69 aU; p<0.01) and an increase in microvascular flow velocity (pre-revascularization: 0.25±0.13; post-revascularization: 0.59±0.25 s−1; p=0.02). Conclusion: These findings suggest that patients with PAD compensate for the conduit artery blood flow impairment with an increase in microvascular blood volume to maintain muscle perfusion during submaximal exercise. Clinical Impact The findings from this study support the notion that the impairment in conduit artery blood flow in patients with PAD leads to compensatory changes in microvascular blood volume and flow velocity to maintain muscle microvascular perfusion during submaximal leg exercise. Moreover, this study demonstrates that these microvascular changes are reversed and become normalized with successful lower-limb endovascular revascularization.

Evaluation of Infrapopliteal Revascularization for Ischemic Diabetic Foot in Hemodialysis Patients

Objective: To evaluate the outcomes of infrapopliteal revascularization for diabetic hemodialysis patients with ischemic diabetic foot. Methods: From 2017 to 2021, 250 patients with diabetic foot identified as stage C (ischemia) or D (ischemia and infection) of Texas Wound Classification underwent successful infrapopliteal surgical and endovascular revascularization at the vascular surgery department of Moulay Ismail Military Hospital in Meknes. The outcomes were retrospectively compared in hemodialyzed patients (HD group: 48 patients), and not hemodialyzed patients (not HD group: 202 patients) during the same period. Results: Outcomes were expressed as healing, major amputation, revascularization patency and mortality rate. Hemodialysis was a negative predictor of healing and a positive predictor of major amputation. Outcomes for HD and not HD groups were respectively: healing (62.5 vs 82 %), major amputation (37.5 vs 18 %). There was no significant difference in revascularization primary patency between the two groups (70 vs 73.6%). The mortality rate was higher in the HD group than in the not HD group (21 vs 10%). Conclusions: Our study shows that ischemic diabetic foot associated with hemodialysis have a bad prognosis with a higher risk of major amputation and death. Infrapopliteal revascularization with infection control should be performed to enhance the rate of limb salvage in this risk group.

Abstract WP153: Abnormal Cerebral Blood Flow Determined By Transcranial Doppler In Patients With Anterior Circulation Large-vessel Occlusion Stroke And Successful Endovascular Recanalization

Background: Almost half of large-vessel occlusion (LVO) stroke patients have unfavorable outcomes despite successful endovascular revascularization. We aim to characterize post-revascularization cerebral blood flow (CBF) determined by transcranial Doppler (TCD) and explore whether abnormal CBF associates with in-hospital outcomes in this population. Methods: We analyzed 105 stroke patients with anterior circulation LVO who had successful endovascular revascularization (Thrombolysis in Cerebral Infarction 2b-3) and CBF assessment by TCD within 48 hours of recanalization. TCD parameters recorded at the ipsilateral middle cerebral artery included mean flow velocity, peak systolic velocity, pulsatility index (PI), and resistance index (RI). CBF was classified according to the Thrombolysis in Brain Ischemia (TIBI) score into dampened flow (score of 3), stenotic flow (score of 4), and normal flow (score of 5). We explored unadjusted associations between post-revascularization CBF and hospitalization outcomes including reduced disability at discharge (modified Rankin Score [mRS] 0-2), home disposition, and in-hospital mortality. Results: Table 1 summarizes study population characteristics. Overall, 62 (59.1%) individuals had normal CBF, 29 (27.6%) had stenotic flow, and 14 (13.3%) had dampened flow. Patients with abnormal CBF showed a trend towards lower likelihood of mRS 0-2 at discharge (32.1% vs. 44.2%; p=0.20) and home disposition (28.1% vs. 46.6%; p=0.08). TCD parameters were not associated with disability at discharge or home disposition. However, in-hospital mortality was significantly associated with elevated PI (1.3 ± 0.4 vs. 1.1 ± 0.5; p&lt;0.01) and RI (0.7 ± 0.1 vs. 0.6 ± 0.1; p&lt;0.01). Conclusion: A noteworthy fraction of anterior circulation LVO stroke patients had TCD-defined abnormal CBF despite successful revascularization. Abnormal CBF and increased vascular resistance may relate to unfavorable outcomes in this population.

Predictors of 30-day mortality after endovascular thrombectomy for large vessel occlusion in the elderly.

Elderly acute ischemic stroke (AIS) patients (≥80 years) would have dismal clinical outcomes even after successful endovascular revascularization for large vessel occlusion (LVO) in the anterior circulation. We aimed to identify predictors of 30-day mortality after endovascular thrombectomy (EVT) in the elderly. We included older patients who underwent EVT for AIS due to LVO within 6 h after stroke onset in the anterior circulation between 2017 and 2019. Patients due to posterior circulation stroke, with intracerebral hemorrhage (ICH) or pre-stroke modified Rankin Scale (mRS) score of 4 and 5 were excluded. The primary outcome was mortality within 30 days of EVT. The association between clinical, imaging, procedural, follow-up imaging and mortality were analyzed. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b or 3. Possible predictors of 30-day mortality were assessed by univariate and multivariable logistic regression. Total 238 AIS patients eligible for EVT were identified with 58 patients aged 80 years or more. 48 patients met inclusion criteria. Median age was 86 years (age range, 82-102 years). Successful reperfusion was achieved in 38 (79.2%) patients. The 30-day and 90-day mortality rate were 25% and 33.3%, respectively. The independent predictors of 30-day mortality were collateral scores <3 on mCTA (adjusted OR, 16.571; 95% CI, 1.041-263.868; p = 0.047) and number of passes (adjusted OR, 2.475; 95% CI, 1.047-5.847; p = 0.039). Lower collateral scores on mCTA and higher number of passes in thrombectomy were independently predictive of 30-day mortality in the elderly.

Utility of Angiographic Metrics of Perfusion as a Predictor of Successful Endovascular Revascularization of Atherosclerotic Peripheral Vascular Disease

Angiography for peripheral vascular disease can provide physiologic perfusion data, in addition to the more common use as an anatomic assessment of arterial stenosis. The primary objective of the present study was to investigate the feasibility of angiographic metrics of perfusion as a predictor of successful endovascular revascularization (ER) of peripheral vascular disease.

Strategies to Minimize Iodinated Contrast Volume in Patients with Chronic Kidney Disease Undergoing Peripheral Vascular Interventions

Peripheral vascular interventions (PVI) utilize iodinated contrast medium (ICM) to visualize intravascular lesions and guide therapy. The use of ICM carries a risk of postcontrast acute kidney injury (PC-AKI), which is increased in the elderly and in patients with chronic kidney disease (CKD). Furthermore, the risk of PC-AKI increases with the volume of ICM used. This paper reports a 94-year-old patient with CKD stage 4 who presented with chronic limb threatening ischemia. He underwent successful endovascular revascularization using a combination of CO2 and dilute ICM (total volume = 6.5 mL). The case demonstrates strategies to minimize ICM during PVIs.