Treatment Of Acute Limb Ischemia Research Articles

Contraindications to tissue plasminogen activator thrombolysis for acute lower extremity ischemia.

Previous randomized prospective trials have demonstrated the effectiveness of transcatheter tissue plasminogen activator (tPA) thrombolysis in treating acute limb ischemia (ALI) compared to conventional surgery. These pivotal trials have also highlighted contraindications for these procedures. Given recent advancements in techniques and technology, our aim is to reassess the relevance of these contraindications in contemporary practice. A retrospective chart analysis was performed utilizing the inpatient medical records of consecutive individuals who underwent tPA treatment for acute limb ischemia (ALI) from September 2016 to April 2022. Inclusion criteria encompassed patients aged 18 and above displaying clinical symptoms and imaging evidence of ALI within 14 days. All patients received tPA with suction thrombectomy following the fast-track thrombolysis protocol. In cases where a persistent thrombus or stenosis was detected, catheter-directed thrombolysis was considered overnight, and patients underwent angiography and reassessment in the operating room subsequently. Patients were classified into two groups based on the STILE trial's established contraindications for endovascular treatment in acute limb ischemia (ALI). If a patient had any of these contraindications, they were placed in the contraindicated group. This resulted in 24 patients (32%) in the contraindicated group and 52 patients (68%) in the non-contraindicated group. No statistically significant demographic variations were observed between these groups. Contraindications in our study included uncontrolled hypertension (12/24, 50%), recent invasive procedures (7/27, 29%), history of cerebrovascular accident (CVA) within 6 months (3/24, 12%), and intracranial malformation/neoplasms (2/24, 8%). Three patients within the non-contraindicated group experienced bleeding complications: two with puncture site bleeds and one with nasal bleeding. In contrast, one patient in the contraindicated group had transient postoperative hematuria. There were no significant differences in bleeding complications observed between the two groups (p = .771). Additionally, no amputations were observed within our population. In light of our study results and advancements in endovascular therapies, we can now safely and efficiently treat patients who were previously considered contraindicated for such treatments. It is essential to individualize treatments and carefully balance the risks and benefits of endovascular versus open surgical revascularization for these patients. Additionally, we believe that the nearly 30-year-old guidelines for endovascular therapies need to be revisited and updated to align with modern technology.

Utilization of EKOS Ultrasound-Accelerated Thrombolysis in the Treatment of Acute Limb Ischemia

Utilization of EKOS Ultrasound-Accelerated Thrombolysis in the Treatment of Acute Limb Ischemia

Popliteal artery aneurysm is a cause that should not be forgotten in acute limb ischemia

Aim: The aim of our study is to determine the amputation rates in patients with acute limb ischemia (ALI) who were monitored for one year and to identify the factors influencing these rates, as well as to examine the effects of popliteal artery aneurysm (PAA) on acute limb ischemia. Material and Methods: Between January 2022 and January 2023, a retrospective analysis was conducted on 103 patients who presented to our clinic with ALI. Among patients, 59.2% (n=61) were not amputated and classified as Group-1. Group-2 comprised 40.8% of the patients (n=42) all of whom required amputation in the follow-up period. Cases of ALI attributable to atrial fibrillation and trauma were excluded from the study. Both groups were compared in terms of amputation rates in the follow-up period and demographic characteristics. All patients were Rutherford Stage IIa and IIb. Unsalvageable Rutherford Stage3 patients were also excluded. All patients who underwent amputation had exclusively undergone embolectomy; no amputations were observed in patients with PAA (p=0.01). Results: The average age of the patients was 70.01±12.56 years (min 31-max 89). Seventy-five patients were male (72.8%), while twenty-eight patients were female (27.2%). The etiology of ALI was identified as thromboembolic events secondary to atherosclerotic peripheral artery disease (APAD) in 92 patients (89.3%), and as PAA in 11 patients (10.7%). Sixty-six (64.7%) patients underwent solely embolectomy, nine (8.7%) patients received combined embolectomy with thrombolytic therapy and twenty-eight patients (27.4%) patients underwent surgical revascularization. In the first year follow-up, 42 (41.2%) patients had undergone amputation. All patients who underwent amputation had exclusively undergone embolectomy; no amputations were observed in patients with PAA (p=0.01). Conclusion: Blinded embolectomy may be the first line surgical treatment for ALI but it has higher amputation rates in 1-year follow-up. While PAA is considered one of the rare causes of ALI, it should be kept in mind as one of the etiological factors in patients presenting with ALI. With appropriate treatment, amputation rates are significantly lower in patients with PAA.

Contemporary National Incidence and Outcomes of Acute Limb Ischemia

Acute Limb Ischemia (ALI) is a morbid and deadly diagnosis. However, existing epidemiologic studies describing ALI predate the introduction of the Affordable Care Act in 2010 and direct oral anticoagulants in 2011. Thus, we synergized the National Inpatient Sample (NIS) and United States (U.S.) Census to define contemporary trends in the incidence, treatment, and outcomes of ALI in the US. We included emergent admissions of adults with primary diagnosis of lower extremity ALI in survey-weighted NIS data (2005-2020). Mann-Kendal trend test evaluated ALI incidence (primary outcome), anticoagulation usage, insurance coverage, revascularization type, and in-hospital amputation/death. Multivariable logistic regression quantified covariate associations with in-hospital amputation/death. Of 582,322,862 estimated hospitalizations in the NIS, 227,440 met inclusion criteria (mean age 68.80 years, 49.94% women, 76.66% White). ALI incidence peaked in 2006 (7.16/100,000 person-years) but has declined since 2015 to 4.16/100,000 person-years in 2020 (ptrend=.008). Endovascular revascularization, anticoagulation, and Medicaid coverage increased, while self-pay insurance decreased (ptrend<.05). Amputation rates significantly decreased from 8.04% to 6.54% (ptrend=.01) while death rate remained at 5.59% (ptrend=.16) over the study period. Pre-hospitalization anticoagulation was associated with decreased amputation (aOR=0.74 [95%CI 0.65-0.84]) and death (aOR=0.50 [95%CI 0.43-0.57]). When controlling for covariates, women had a higher risk of death (aOR=1.17 [95%CI 1.07-1.27], p<.0001), while Black patients had a higher risk of amputation (aOR=1.24 [95%CI 1.10-1.41], p<.0001). Our U.S. population based epidemiological study demonstrates that ALI incidence and in-hospital amputation rates are decreasing, while mortality remains unchanged. We further highlight the ongoing need for ALI investigation specifically as it relates to access to care, antithrombotic therapy use, treatment strategy, and strategies to combat gender and racial disparities.

Paradigm Shift of Interventional Strategies and Outcomes for Acute Limb Ischemia Post-Pandemic.

We performed a large-scale comparison of patients treated for acute limb ischemia (ALI) in the pre-COVID (2017-2019) and COVID (2020-2022) eras to evaluate changes in interventional strategies and compare factors associated with adverse outcomes. We sought to characterize patient outcomes in an evolving ALI treatment algorithm in response to pandemic-associated presentation delays and rapid technological advancements in mechanical thrombectomy (MT). Using the TriNetX global research network, we conducted a multicenter query across 80 health care organizations (HCOs) spanning 4 countries for patients treated for ALI. Propensity score matching was performed to account for comorbidities. Risk of adverse outcomes within 30 days was calculated for each era, including re-intervention (RI30), major/minor amputation, and death. Patients were then stratified by initial intervention: open revascularization (OR), MT, or catheter-directed thrombolysis and adjunctive endovascular procedures alone (CDT/EP). Risk of adverse outcomes was compared between treatment groups of the same era. After propensity score matching, the pre-COVID era and COVID era cohorts included 7344 patients each. COVID era patients experienced a statistically significant higher risk of 30-day mortality (RR=1.211, p=0.027). Mechanical thrombectomy interventions were performed more frequently in the COVID era (RR=1.314, p<0.0001). Comparing outcomes between treatment groups, MT patients required RI30 more than OR patients (pre-COVID: RR=2.074, p=0.006; COVID: RR=1.600, p=0.025). Open revascularization patients had higher 30-day mortality (pre-COVID: RR=2.368, p<0.0001; COVID: RR=2.013, p<0.0001) and major amputations (pre-COVID: RR=2.432, p<0.0001; COVID: RR=2.176, p<0.0001) than CDT/EP. Pre-COVID CDT/EP patients were at higher risk for RI30 (RR=1.449, p=0.005) and minor amputations (RR=1.500, p=0.010) than OR. The MT group had higher major amputation rates than CDT/EP (pre-COVID: RR=2.043, p=0.019; COVID: RR=1.914, p=0.007). COVID-era MT patients had greater 30-day mortality (RR=1.706, p=0.031) and RI30 (RR=1.544, p=0.029) than CDT/EP. Significant shifts toward an MT-based approach have been observed in the last 3 years. Although MT required more RI30 than OR, there was no associated consequence of mortality and limb salvage. The increased mortality seen among COVID-era patients could be explained by delayed presentation, as well as poorly understood pro-thrombogenic or pro-inflammatory mechanisms related to the first waves of COVID. More research is necessary to determine an optimal treatment algorithm. Comorbid risk factors and severity of ischemia must be carefully considered before selecting an interventional strategy to prevent adverse outcomes and maximize limb salvage. Open revascularization strategies are associated with increased mortality and limb loss compared to less-invasive thrombolytic therapy alone. Mechanical thrombectomy (MT)-based approaches have been increasingly used in the last 3 years. Patients receiving MT are more likely to require reintervention within 30 days.

Machine Learning to Predict Outcomes of Endovascular Intervention for Patients With PAD

Endovascular intervention for peripheral artery disease (PAD) carries nonnegligible perioperative risks; however, outcome prediction tools are limited. To develop machine learning (ML) algorithms that can predict outcomes following endovascular intervention for PAD. This prognostic study included patients who underwent endovascular intervention for PAD between January 1, 2004, and July 5, 2023, with 1 year of follow-up. Data were obtained from the Vascular Quality Initiative (VQI), a multicenter registry containing data from vascular surgeons and interventionalists at more than 1000 academic and community hospitals. From an initial cohort of 262 242 patients, 26 565 were excluded due to treatment for acute limb ischemia (n = 14 642) or aneurysmal disease (n = 3456), unreported symptom status (n = 4401) or procedure type (n = 2319), or concurrent bypass (n = 1747). Data were split into training (70%) and test (30%) sets. A total of 112 predictive features (75 preoperative [demographic and clinical], 24 intraoperative [procedural], and 13 postoperative [in-hospital course and complications]) from the index hospitalization were identified. Using 10-fold cross-validation, 6 ML models were trained using preoperative features to predict 1-year major adverse limb event (MALE; composite of thrombectomy or thrombolysis, surgical reintervention, or major amputation) or death. The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). After selecting the best performing algorithm, additional models were built using intraoperative and postoperative data. Overall, 235 677 patients who underwent endovascular intervention for PAD were included (mean [SD] age, 68.4 [11.1] years; 94 979 [40.3%] female) and 71 683 (30.4%) developed 1-year MALE or death. The best preoperative prediction model was extreme gradient boosting (XGBoost), achieving the following performance metrics: AUROC, 0.94 (95% CI, 0.93-0.95); accuracy, 0.86 (95% CI, 0.85-0.87); sensitivity, 0.87; specificity, 0.85; positive predictive value, 0.85; and negative predictive value, 0.87. In comparison, logistic regression had an AUROC of 0.67 (95% CI, 0.65-0.69). The XGBoost model maintained excellent performance at the intraoperative and postoperative stages, with AUROCs of 0.94 (95% CI, 0.93-0.95) and 0.98 (95% CI, 0.97-0.99), respectively. In this prognostic study, ML models were developed that accurately predicted outcomes following endovascular intervention for PAD, which performed better than logistic regression. These algorithms have potential for important utility in guiding perioperative risk-mitigation strategies to prevent adverse outcomes following endovascular intervention for PAD.

Treatment for Acute Limb Ischemia - Japanese Real-World Data From Active Facilities.

Treatment for Acute Limb Ischemia - Japanese Real-World Data From Active Facilities.

Acute peripheral ischemia associated with SARS-CoV-2 infection: experience in diagnosis and treatment

The study aimed to evaluate the outcomes of treatment of acute limb ischemia (ALI) in patients with novel coronavirus infection (COVID-19). The study group included 62 patients; 67 extremities: upper – 19 (28.3%), lower – 48 (71.6%). Distribution of cases according to ALI grades (Rutherford): I – 7 (10.4%), IIA – 10 (14.9%), IIB – 34 (50.7%), III – 16 (23.8%). COVID-19 was confirmed by the polymerase chain reaction test; 45 (72.5%) patients being documented to have lung injury. Fifty (80.6%) patients underwent surgical treatment on 52 limbs. Amputation rate during hospitalization (9.4±9 days) – 19.4%; mortality rate – 43.5%, being significantly influenced by the presence or absence of lung damage – 55.5% vs. 11.7% (P=0.002; χ² test). The following serum biomarkers served as potential predictors of mortality: C-reactive protein to albumin ratio, platelets to lymphocytes and fibrinogen to albumin ratio. At follow-up of 21 (25%-75%IQR 19-28) months overall and amputation-free survival rates were 56.4% and 57.1%.

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

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

Outcomes After Open Surgical, Hybrid, and Endovascular Revascularization for Acute Limb Ischemia.

To report the performance of surgical treatment (ST), hybrid treatment (HT), and endovascular treatment (ET) for patients with acute limb ischemia (ALI). This is a retrospective, comparative study of all consecutive patients with ALI treated in 2 tertiary centers between April 2010 and April 2020. Amputation and/or death (amputation-free survival; AFS) was the primary composite endpoint. Mortality, major amputation, and reintervention during follow-up were additionally analyzed. Proportional hazards modeling was used to identify confounders, results are presented as hazard ratio (HR) and 95% confidence intervals (CIs). In total, 395 patients (mean age=71.1±13.6 years; 51.1% female) were treated during the study period. Surgical treatment was preferred in 150 patients (38%), while 98 were treated by HT (24.8%) and 147 by ET (37.2%). Rutherford class IIa was the most common clinical presentation in the ET group (50.3%), whereas Rutherford IIb was most common in the ST (54%) and HT (48%) groups (p<0.001). Significantly, more patients presented with a de novo lesion in the ST and HT groups (79.3% and 64.3%, respectively) compared with ET (53.7%; p<0.001). Median follow-up was 20 months (range=0-111 months). In the multivariate analysis, ET showed significantly better AFS during follow-up compared with ST (HR=1.89, 95% CI=1.2-2.9, p<0.001) and HT (HR=1.73, 95% CI=1.1-3.1, p<0.001). Mortality during follow-up was also significantly lower after ET compared with ST (HR=2.21, 95% CI=1.31-3.74, p=0.003) and HT (HR=2.04, 95% CI=1.17-3.56, p=0.012). Endovascular treatment was associated with lower amputation rate compared with ST (HR=2.27, 95% CI=1.19-4.35, p=0.013) but was comparable with HT (HR=2.00, 95% CI=0.98-4.06, p=0.055). Reintervention rates did not differ significantly between the groups (ET vs ST: HR=1.52, 95% CI=0.99-2.31, p=0.053; ET vs HT: HR=1.3, 95% CI=0.81-2.07, p=0.27). Endovascular treatment for ALI was associated with improved AFS and comparable reintervention rates compared with open surgical and hybrid therapy. Treatment of acute lower limb ischemia remains a challenge for clinicians with high morbidity and mortality rates. Endovascular revascularization is considered first line treatment for many and hybrid treatments are becoming more common, however data is limited to either old trials, small series or with short follow-up. We present herein our 10-year experience with all available devices and techniques for open surgical, endovascular and hybrid acute limb ischemia treatments and compare their outcomes.

Patología vascular aguda, isquemia arterial aguda y síndrome aórtico agudo

Acute vascular pathology, and specifically acute limb ischemia and acute aortic syndrome (AAS), have a high morbidity and mortality. It is necessary to make a correct diagnosis and provide treatment to reduce it in a short period of time.Acute limb ischemia is the result of a sudden decrease in blood supply to the limbs. It progresses with signs of hypoperfusion, pain, and functional weakness in the affected limb. AAS includes three clinical entities: dissection, intramural hematoma, and penetrating atherosclerotic ulcer. They progress with sudden, piercing pain associated with hypertension.In regard to acute limb ischemia, clinical suspicion is essential and, although they are not indispensable, imaging studies can confirm the diagnosis and are useful in surgical planning. In the case of AAS, an angio-CT scan is the diagnostic test of choice. Systemic anticoagulation is the initial treatment for acute limb ischemia. In many cases, revascularization surgery is also necessary. In cases of type A AAS, the treatment is emergency surgery. For type B, the initial treatment is medical, with monitoring and blood pressure control.

Safety and efficacy of interventional treatment of acute limb ischemia in Germany 2021

PurposeInterventional procedures have become a mainstay in the therapy of acute limb ischemia caused by embolism or arterial thrombosis. Treatment options include pharmacological thrombolysis (PT) and mechanical thrombectomy (MT). The aim of this study was to evaluate success and major complication rates of interventional radiological treatments of arterial embolism and thrombosis in Germany in 2021 and to compare their results with accepted international quality standards.Materials and methodsData for PT and MT for 2021 was obtained from the quality management system of the German interventional radiological society (DeGIR). 2431 PT and 1582 MT procedures were documented for 2021, with 459 combinations of PT and MT. Data was analysed for technical and clinical success rates, as well as major complication rates such as intracranial bleeding, major bleeding, distal embolization, aneurysm formation, organ-failure and cardiac-decompensation.ResultsPT alone had technical and clinical success rate of 90.21% and 81.08%, respectively. MT alone had technical and clinical success rates of 97.41% and 95.39%, respectively. MT&PT had technical and clinical success rates of 91.07% and 84.75%, respectively. Major complications were: distal embolization (PT:2.02%; MT:1.74%; PT&MT:2.61%), major bleeding (PT:0.94%; MT:1.14%; PT&MT:0.87%), aneurysm formation (PT:0.33%;MT: 1.14%;PT&MT: 0%), intracranial bleeding (PT:0.16%;MT:0%;PT&MT:0.22%), cardiac-decompensation (PT:0.21%;MT: 0.06%;PT&MT:0%) and organ-failure (PT:0%;MT:0.06%;PT&MT:0.22%).Technical and clinical success rates were higher, while complication rates were lower than the corresponding threshold recommended by the Society of Interventional Radiology for percutaneous management of acute lower-extremity ischemia.ConclusionTreatment of arterial embolism and thrombosis performed by interventional radiologists in Germany is effective and safe with outcomes exceeding internationally accepted standards.

Impact of Revascularization Technique on the Outcomes of Peripheral Graft Revision Procedures

The acute occlusion of a peripheral bypass graft leads to acute limb ischemia (ALI) and threatens the viability of the limb if left untreated. The aim of the present study was to analyze the results of surgical and hybrid revascularization techniques for patients with ALI due to peripheral graft occlusions. A retrospective analysis of 102 patients undergoing treatment for ALI due to peripheral graft occlusion between 2002 and 2021 was carried out at a tertiary vascular center. Procedures were classified as surgical when only surgical techniques were used and as hybrid when surgical procedures were combined with endovascular techniques such as balloon or stent angioplasty or thrombolysis. Endpoints were primary and secondary patency and amputation-free survival after 1 and 3years. Of all patients, 67 met the inclusion criteria, 41 were treated surgically and 26 by hybrid procedures. There were no significant differences in the 30-day patency rate, 30-day amputation rate, and 30-day mortality. The 1- and 3-year primary patency rates were 41.4% and 29.2% overall, respectively; 45% and 32.1% in the surgical group, respectively; and 33.2% and 26.6% in the hybrid group, respectively. The 1- and 3-year secondary patency rates were 54.1% and 35.8% overall, respectively; 52.5% and 34.2% in the surgical group, respectively; and 54.4% and 43.5% in the hybrid group, respectively. The 1- and 3-year amputation-free survival rates were 67.5% and 59.2%, overall, respectively; 67.3% and 67.3% in the surgical group, respectively; and 68.5% and 48.2% in the hybrid group, respectively. There were no significant differences between the surgical and the hybrid groups. The results of surgical and hybrid procedures after bypass thrombectomy for ALI to eliminate the cause of infrainguinal bypass occlusion are comparable with good midterm results in terms of amputation-free survival. New endovascular techniques and devices need to be established in comparison to the results of these proven surgical revascularization methods.

The Classical 6-P of Acute Limb Ischemia

Acute limb ischemia (ALI) is a surgical emergency and often threatens limb viability. This is a case of a 45-year-old patient who presented with the classical six Ps of ALI. A 45-year-old lady with underlying hypertension and heart failure presented with acute right leg pain arriving by ambulance at the Emergency Department within 4 hours of the symptom. The patient was clinically obese and seemed very uncomfortable as evidenced by her writhing in pain. She was borderline tachycardic and hypertensive. The cardiopulmonary and abdominal examinations were unremarkable. On extremity examination, she was unable to move her right leg starting from the knee caudally. The leg appeared mottling and cold. On vascular examination, there was no abdominal or femoral bruit but there was a diminished pulsation of the right femoral, dorsalis-pedis and posterior-tibialis arteries as confirmed by Doppler compared to the contralateral side. On the neurological examination, the sensation was absent and no pain upon the passive stretch. Ankle-Brachial-Systolic Index (ABSI) was 0.7. As evidenced by pain, pallor, pulselessness, poikilothermia, paralysis, and paresthesia, clinical diagnosis of acute right leg ischemia was established with most likely vascular occlusion proximal to the left femoral artery. The vascular team was urgently referred. Electrocardiogram showed sinus tachycardia. Bedside ultrasound revealed normal aortic root size and neither aortic dissection nor aneurysm. 2-point compression tests were fully compressible and X-ray films showed no fracture. Creatinine Kinase was 65 units/litre whereas other blood parameters were unremarkable. She was then classified as Rutherford IIB and underwent a right femoral thromboembolectomy. The presentation of ALI requires rapid diagnosis and appropriate management as it is time-sensitive and limb-threatening. Emergency physicians should be aware of advances in endovascular therapies as a recommended option for the treatment of ALI. International Journal of Human and Health Sciences Supplementary Issue: 2023 Page: S23

Etiology, Pathology and Treatment of Acute Limb Ischemia

When a blood vessel that provides blood to a limb becomes blocked it can result in oxygen and nutrients reaching the limb. This medical situation, referred to as limb ischemia (ALI), is a pressing issue that demands immediate medical intervention. This interruption can lead to tissue damage and the potential risk of limb loss. This abstract provides an overview of the management of ALI, which includes both endovascular treatments. It emphasizes the importance of considering patient factors and ensuring intervention. The management of ALI primarily relies on therapy, which involves using anticoagulation to prevent blood clot formation providing pain relief and, reducing metabolic demands through analgesics, ensuring perfusion through fluid resuscitation improving microcirculation with vasodilators and addressing infection risks with antibiotics. Several techniques, including endovascular techniques, offer options such as thrombolysis to dissolve clots that are blocking arterial flow. Successfully managing ALI requires assessment of the causes, severity of ischemia, availability of vascular expertise, and taking into account patient preferences and any existing health conditions. It is crucial to diagnose ALI and initiate treatment without delay in order to save viable limbs. The expertise and teamwork of healthcare professionals play a role in customizing interventions according to needs. In conclusion, effective management of ALI demands an approach that balances therapies with endovascular interventions while prioritizing patient-centered care and swift action. The preservation of limb function and overall well-being greatly depend on these considerations.

Acute limb ischemia : Quick review for residents in interventional radiology

Knowledge of diagnosis and treatment of acute limb ischemia is essential to preserve limb viability and prevent irreversible damage. Abrief review of treatment options, patient selection, and management in acute limb ischemia is provided for residents in interventional radiology. The most commonly used interventional treatment options in acute limb ischemia including case studies and recommendations are provided. In acute limb ischemia, the decision between therapeutic procedures (interventional or surgical) depends on the clinical stage. There are three main interventional procedures: catheter-directed thrombolysis, thromboaspiration, and mechanical thrombectomy using specialized catheters; acombination of these procedures is also possible. The decision depends on various factors, some of which are center-specific, and should therefore always be made by interdisciplinary consensus. After near-complete revascularization, the cause should be sought and eliminated. In acase of suspected acute limb ischemia, patients should ideally be taken to an interdisciplinary center with interventional radiology and vascular surgery. After clinical evaluation and noninvasive imaging, adecision regarding possible therapeutic options can be made.

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.

Impact of Chronic Kidney Disease on In-Hospital Outcomes of Hospitalizations With Acute Limb Ischemia Undergoing Endovascular Therapy

Purpose: Studies on outcomes related to endovascular treatment (EVT) in advanced stages of chronic kidney disease (CKD) and end-stage renal disease (ESRD) among hospitalizations with acute limb ischemia (ALI) are limited. Methods: The Nationwide Inpatient Sample was quarried from October 2015 to December 2017 to identify the hospitalizations with ALI and undergoing EVT. The study population was subdivided into 3 groups based on their CKD stages: group 1 (No CKD, stage I, stage II), group 2 (CKD stage III, stage IV), and group 3 (CKD stage V and ESRD). The primary outcome was all-cause in-hospital mortality. Results: A total of 51 995 hospitalizations with ALI undergoing EVT were identified. The in-hospital mortality was significantly higher in group 2 (OR = 1.17; 95% CI 1.04 – 1.32, p=0.009) and group 3 (OR = 3.18; 95% CI 2.74–3.69, p<0.0001) compared with group 1. Odds of minor amputation, vascular complication, atherectomy, and blood transfusion were higher among groups 2 and 3 compared with group 1. Group 2 had higher odds of access site hemorrhage compared with groups 1 and 3, whereas group 3 had higher odds of major amputation, postprocedural infection, and postoperative hemorrhage compared with groups 1 and 2. Besides, groups 2 and 3 had lower odds of discharge to home compared with group 1. Finally, the length of hospital stay and cost of care was significantly higher with the advancing CKD stages. Conclusion: Advanced CKD stages and ESRD are associated with higher mortality, worse in-hospital outcomes and higher resource utilization among ALI hospitalizations undergoing EVT. Clinical Impact Current guidelines are not clear for the optimum first line treatment of acute limb ischemia, especially in patients with advanced kidney disease as compared to normal/mild kidney disease patients. We found that advanced kidney disease is a significant risk factor for worse in-hospital morbidity and mortality. Furthermore, patients with acute limb ischemia and advanced kidney disease is associated with significantly higher resource utilization as compared to patients with normal/mild kidney disease. This study suggests shared decision making between treating physician and patients when considering endovascular therapy for the treatment of acute limb ischemia in patients with advanced kidney disease.

AhR regulates VEGF expression by promoting STAT1 transcriptional activity, thereby affecting endothelial angiogenesis in acute limb ischemia

BackgroundAngiogenesis has great potential in the treatment of acute limb ischemia (ALI). Here, we aimed to investigate the effect and mechanism of Aryl hydrocarbon receptor (AhR) on angiogenesis in ALI. MethodsThe ALI mouse model was constructed by femoral artery ligation, and the cell ischemia injury was induced by Hypoxia/serum deprivation. The laser doppler perfusion imaging was executed to detect the limb blood flow velocity. The tube formation assay was performed to evaluate angiogenesis. The cell viability was measured by 3-(45)-dimethylthiahiazo(-z-y1)-35-di-phenytetrazoliumromide. The cell migration was detected by wound healing assay. Hematoxylin-eosin, immunohistochemistry, immunofluorescence, dual-luciferase reporter gene assay, and Chromatin immunoprecipitation assay were conducted. ResultsIn ALI models, AhR expression was increased and translocated from cytoplasm to nucleus. Besides, necrosis and inflammatory infiltration were also increased in gastrocnemius tissues of model mice. In addition, AhR loss (LV-sh-AhR) promoted cell viability, angiogenesis, and migration, and also elevated the levels of vascular endothelial growth factor (VEGF), Tie2, and Ang2 in HUVEC models with Hypoxia/serum deprivation injury. Meanwhile, the interaction between AhR and signal transducer and activator of transcription 1 (STAT1), as well as STAT1 and VEGF, has also been confirmed. Co-transfection of LV-sh-AhR and LV-STAT1 suppressed cell viability, angiogenesis, and migration of injured HUVECs. Furthermore, injection of AAV2/9-shAhR in vivo also promoted angiogenesis, which was consistent with the in vitro experimental results. ConclusionsIn ALI models, activated AhR was translocated to the nucleus and down-regulated VEGF expression by promoting the transcriptional activity of STAT1, thereby inhibiting endothelial angiogenesis.

Young patients without prior vascular disease are at increased risk of limb loss and reintervention after acute limb ischemia.

The objective of the present study was to categorize the presentation and treatment of acute limb ischemia (ALI) in young patients and compare the adverse outcomes after revascularization compared with that of older patients. All the patients who had presented to a multi-institution healthcare system with ALI from 2016 to 2020 were identified. The presenting features, operative details, and outcomes were included in the present analysis. Patients with existing peripheral arterial disease (acute on chronic) were analyzed separately from those without (de novo thrombosis or embolus). Within these groups, younger patients (age, ≤50years) were compared with older patients (age, >50years). The 3-month major adverse limb event-free survival was the primary outcome. A total of 232 patients (age, 60± 16years; 44% female sex, 87% white race) were included in the analysis. Of the 232 patients, 119 were in the acute on chronic cohort and 113 were in the de novo thrombosis/embolism cohort. Age did not affect the overall outcomes (P= .45) or the outcomes for the acute on chronic group (P= .17). However, in the de novo thrombosis/embolism cohort, patients aged ≤50years had worse major adverse limb event-free survival compared with patients aged >50years (hazard ratio, 2.47; 95% confidence interval, 1.08-5.68; P= .03) after adjustment for Rutherford class, interval from presentation to the operating room, and smoking status. In the de novo thrombosis/embolism group, the operative approach was similar across the age groups (endovascular, 12% vs 14%; open, 48% vs 41%; hybrid, 41% vs 45%; P= .78). In the younger patients, embolism was more likely from a proximal arterial source (71%). In contrast, in the older patients, the source of embolism was more often a cardiac source (86%). The rates of hypercoagulable disease were equal across the age groups (10% vs 10%; P= .95). The In-hospital mortality was 3% overall (acute on chronic, 5%; de novo,3%). Despite advances in interventional options, for patients with ALI due to de novo thrombosis or embolus, younger age was associated with worse short-term limb-related outcomes.