Treatment Of Acute Limb Ischemia Research Articles

Systemic thrombolytic therapy in treatment of acute limb ischemia

Background and aim Owing to the increased risk of morbidity and mortality, the treatment of acute limb ischemia (ALI) is challenging. The authors aimed to investigate the outcomes of thrombolysis in the treatment of ALI and limb salvage. Patients and methods A retrospective observational study was conducted to revise the data of 49 patients who underwent catheter-direct thrombolysis for ALI. A total of 33 cases were at lower limb and 16 cases were at upper limb. The assessed outcomes were primary and secondary patency, survival, amputation-free survival, and conversion to surgery. Results The patients were classified according to the Rutherford classification into class I (52%), class IIa (38%), class IIb (8%), and class III (2%). The primary patency was present in 34% of the patients after the first year and 22% after the second year. On the contrary, 28% of the patients were subjected to conversion to open surgery, 8% were subjected to reintervention, and 6% were subjected to amputation within the first month. The mortality rate within 1 month was 6%. The worst primary and secondary patency rates were seen in the prosthetic grafts in addition to vein bypasses, whereas the native artery was the most successful one regarding the primary patency, secondary patency, and amputation-free survival (P<0.05 for each). Conclusion The thrombolysis of vein bypass and prosthetic grafts did not show technical success as that seen with native artery. Additional treatment at the time of thrombolysis was shown to be associated with better outcomes.

Characteristics and Outcomes of Patients Transferred for Treatment of Acute Limb Ischemia

Patients requiring emergent vascular surgery often undergo transfer from one facility to another for definitive surgical care. In this study, we analyzed morbidity and mortality in patients presenting for emergent lower extremity thrombectomy and embolectomy in the transferred and nontransferred populations. A retrospective analysis of prospectively collected data was performed utilizing the National Surgical Quality Improvement Program (NSQIP) database for all nonelective, emergent lower extremity embolectomy or thrombectomy (Current Procedural Terminology [CPT] 34,201 and 34,203) performed between 2011 and 2014. Demographics, comorbidities, and 30-day complications, and outcomes were compared among patients presenting from home versus those presenting from another hospital, emergency department, or nursing home. Multivariate analysis was performed to determine the association between mode of presentation, major complications, and death. We identified 1,954 patients who underwent emergent lower extremity embolectomy or thrombectomy. 40.7% (795 patients) were identified as transfer patients. Odds of transfer were significantly increased if a patient was functionally dependent (odds ratio OR 1.95,P<0.001) or had a history of chronic obstructive pulmonary disease (COPD) (OR1.348, P=0.05). Odds of transfer were decreased if a patient was of a nonWhite race (OR 0.511, P<0.001). 11.7% (229) patients in the described cohort died within 30days of surgery. Those who died were more likely to present to the treating hospital as a transfer (56.3% vs. 38.6%, P<0.001). In multivariate analysis, transfer status was significantly associated with 30-day mortality (OR 1.9: 95% confidence interval CI 1.40-2.64; P<0.001). Patients transferred from an outside hospital or nursing home who present for emergent vascular procedures demonstrated increased mortality compared to those who present from home direct to the emergency department despite similar comorbid conditions. In addition, race was identified as an independent factor for transfer. Further studies are needed to understand the complex interactions between inter-hospital transfer patterns, emergency vascular surgery presentations, and racial biases to improve outcomes for this population.

Utilization of EKOS (Ultrasound-Accelerated Thrombolysis) in the Treatment of Acute Limb Ischemia: One-Year Outcome Follow-Up

Utilization of EKOS (Ultrasound-Accelerated Thrombolysis) in the Treatment of Acute Limb Ischemia: One-Year Outcome Follow-Up

Conservative treatment of acute limb ischemia in a child - case report

Acute limb ischemia is a rare event in the pediatric population, with an estimated incidence of 26 per 100,000 admissions, the majority of which are associated with trauma or iatrogeny. The ideal treatment for these cases is not well-established in the literature, although there is a tendency to choose noninvasive treatment. We report the case of an infant who suffered ischemia to all four limbs secondary to hemodynamic complications after complex heart surgery and in whom significant tissue preservation was achieved with conservative treatment.

Infusion techniques for peripheral arterial thrombolysis.

Infusion techniques for peripheral arterial thrombolysis.

THE "CLOT" THICKENS: HYPERKALEMIA DUE TO ACUTE LIMB ISCHEMIA IN COVID-19

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been implicated in a devastating inflammatory response resulting in thromboembolic events. Upwards of 40% of patients have been reported to have venous thromboembolism while the incidence of arterial thrombotic events, including acute limb ischemia (ALI), is estimated to be lower at 5%. This case highlights the importance of early recognition and treatment of ALI in COVID-19 to prevent significant morbidity and mortality. CASE PRESENTATION: A 59-year-old man with hypertension and pre-diabetes presented to our facility with tachypnea and hypoxia with oxygen saturation of 80%. He was placed on high flow nasal cannula but required intubation due to respiratory failure. Initial laboratory values revealed D-dimer 460 ng/mL, C-reactive protein 109 mg/L, ferritin 3,282 ng/mL, and creatine kinase 700 U/L. Right soleal vein thrombosis was identified on lower extremity ultrasound and he was started on intravenous heparin with therapeutic levels. On hospital day 4, he became acutely hypotensive and hyperkalemic to 7.9 mmol/L. Physical exam was notable for cold lower extremities with mottling while laboratory values showed lactate 4.1 mmol/L, D-dimer greater than 10,000 ng/mL, ferritin 23,712 ng/mL, and creatine kinase 21,078 U/L. Upon evaluation with lower extremity arterial duplex, there was no Doppler signal detected in the bilateral common femoral, superficial femoral, popliteal, posterior tibial, and anterior tibial arteries. A subsequent CT angiogram revealed extensive bilateral pulmonary emboli, acute total occlusion of the aorta beginning distal to the renal arteries, and extensive lower limb muscle stranding suggestive of ischemic injury. He was taken to the operating room and underwent emergent thrombolysis and thrombectomy. Unfortunately, he suffered severe reperfusion injury and expired shortly after the procedure. DISCUSSION: ALI presents with the 6 Ps: pain, pallor, paralysis, paresthesia, poikilothermia, and pulselessness. In COVID-19, it is estimated that 71% of arterial thrombotic events involve the lower extremities. Patients at risk are noted to be males over the age of 60 with diabetes and hypertension. Diagnosis can be made with duplex ultrasound, CT angiography, or MR angiography. After initiating therapeutic anticoagulation, vascular surgery should be consulted for management options such as catheter-directed thrombolysis, mechanical thrombectomy, or open surgery. CONCLUSIONS: This case highlights the significance of arterial thrombotic events in COVID-19 and the importance of early recognition of ALI. Unexplained hyperkalemia should be thoroughly investigated as it can be a presentation of myonecrosis secondary to ALI. Prompt initiation of anticoagulation and vascular surgery consult are vital in limiting morbidity and mortality. REFERENCE #1: Helms J, Tacquard C, Severac F, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020;46(6):1089-1098. DISCLOSURES: No relevant relationships by Talha Demirci, source=Web Response No relevant relationships by Himanshu Deshwal, source=Web Response No relevant relationships by ron goldenberg, source=Web Response

Analysis of a Novel Inpatient Acute Limb Ischemia Alert System

Acute limb ischemia (ALI) is a surgical emergency that generally develops in the outpatient setting. Hospitalized patients are also at risk for acute limb ischemia, but their presentation may be atypical or altered by medical therapy. Our institution developed an alert system to facilitate the prompt recognition and treatment of ALI that occurs in the inpatient population. We aimed to evaluate the usage of the system after the first 2 years of operation. All ALI alerts from October 2017 to December 2019 were collected from paging records and analyzed for location, timing, and the need for intervention. Alerts undergoing vascular intervention were classified as urgent (within 8 hours) or delayed (after 8 hr). Time and location data were evaluated to determine patterns of usage and true-positive rate of the system. From October 2017 to December 2019, there were 237 ALI alerts obtained from paging records containing time and location information for the alert. More alerts originated from ICUs relative to non-ICU floors (68% vs. 33%, P< 0.001), however a greater proportion of non-ICU floor alerts required intervention compared to ICU alerts (32.0% vs. 5.1%, P < .0001). The highest number of ALI alerts were from the Medical ICU (MRICU) (45.9%) and medical/surgical floors (33.3%), followed by Surgical ICU (20.2%). Alerts were more common within 3 hr of morning and evening nursing shift changes (47.3%, P < 0.001). From the 237 total alerts, the patient was able to be identified retrospectively in 186 cases, and of these 27 resulted in operative interventions (14.5%, positive predictive value), with 11 patients (40.7%) requiring urgent intervention with a median time to intervention of 3.5 hr (range 2.2-4.8), and 16 (59%) alerts undergoing a delayed intervention at a mean of 3 days (range 2-4). A total of 73 (39.2%) alert patients died during their admission, of which 65 (89.0%) were in an ICU, and no deaths were directly related to ALI. The median time to death was 2 days (range 0-95 days), and in 22 cases death occurred <24 hr from time of alert. Our novel hospital-wide ALI alert system demonstrates a 14.5% positive predictive value for ischemia that resulted in an intervention. Alerts were more likely to originate from the ICU setting and during nursing shift changes. Alerts originating from non-ICU floors were 5 times more likely to undergo surgical intervention for ALI. Further analysis is required to assess the effect of this system on patient safety, outcome, and allocation of institutional resources.

Utilization of Ultrasound-Accelerated Thrombolysis in the Treatment of Acute Limb Ischemia in Patients With Failed Restoration of Flow With Initial Thrombectomy

Many persons with opioid use disorder (OUD) initiate medication for opioid use disorder (MOUD) with one clinic and switch to another clinic during their course of treatment. These switches may occur for referrals or for unplanned reasons. It is unknown, however, what effect switching MOUD clinics has on continuity of MOUD treatment or on overdoses.To examine patterns of switching MOUD clinics and its association with the proportion of days covered (PDC) by MOUD, and opioid-related overdose.Cross-sectional retrospective analysis of Pennsylvania Medicaid claims data.MOUD clinic switches (i.e., filling a MOUD prescription from a prescriber located in a different clinic than the previous prescriber), PDC, and opioid-related overdose.Among 14,107 enrollees, 43.2 % switched clinics for MOUD at least once during the 270 day period. In multivariate regression results, enrollees who were Non-Hispanic black (IRR = 1.43; 95 % CI = 1.24–1.65; p < 0.001), had previous methadone use (IRR = 1.32; 95 % CI = 1.13–1.55; p < 0.001), and a higher total number of office visits (IRR = 1.01; CI = 1.01−1.01; p < 0.001) had more switches. The number of clinic switches was positively associated with PDC (OR = 1.12; 95 % CI = 1.10–1.13). In secondary analyses, we found that switches for only one MOUD fill were associated with lower PDC (OR = 0.97; 95 % CI = 0.95−0.99), while switches for more than one MOUD fill were associated with higher PDC (OR = 1.40; 95 % CI = 1.36–1.44). We did not observe a relationship between opioid-related overdose and clinic switches.Lack of prescriber continuity for receiving MOUD may not be problematic as it is for other conditions, insofar as it is related to overdose and PDC.

Increased collateral flow by rescue femorofemoral bypass dissolved residual thrombus in implanted iliofemoral artery stents: a case report

BackgroundFailed aortofemoral and femoropopliteal bypass grafts in the lower extremity artery usually result in acute limb ischemia. Endovascular treatment and surgical revascularization have been reported for limb salvage.Case presentationA 72-year-old Japanese man was admitted with acute limb ischemia due to failed aortofemoral and femoropopliteal bypass grafts. Endovascular treatment with balloon angioplasty, thrombectomy, and stent implantation in the long chronic total occlusion from the right common iliac artery to the superficial femoral artery did not result in efficient flow due to thrombus transfer from a failed aortofemoral bypass graft. However, a rescue femorofemoral bypass (the left femoral to the right deep femoral artery) improved his symptoms, and implanted in-stent flow was gradually recovered. Lower extremity angiography performed 5 months later confirmed the patency of the iliofemoral in-stent flow. However, the femorofemoral bypass graft was unfortunately occluded due to the progression of left external iliac artery stenosis. The patency of the iliofemoral in-stent flow was confirmed at 1 year by ultrasonography.ConclusionsImprovement of the deep femoral artery flow plays an important role in the treatment of acute limb ischemia due to failed aortofemoral and femoropopliteal bypass grafts. Thus, increased collateral circulation to the periphery through the deep femoral artery dissolved the remaining in-stent thrombus in the iliofemoral artery.

Navigating between the science and art of acute limb ischemia treatment

The diagnosis and treatment of acute limb ischemia (ALI) has long been a fierce adversary that has evolved over the last several decades with scientific advancements in endovascular therapy.History and physical examination remain the mainstay of diagnosis enhanced by detailed imaging to guide therapy. Many endovascular tools are available for prompt restoration of flow that compliment traditional surgical options. These devices incorporate the mechanical removal of thrombus and the chemical dissolution of thrombus . Medical decision-making for ALI patients must take into account the patient characteristics, anatomic variables, mechanism of ischemia, degree of ischemia, and operator skill to employ the right strategy for the right patient. This moving target challenges scientific study, making the therapeutic bedside decision making an artform. We present an overview of the field, supportive data, and a treatment algorithm that hopefully captures this delicate balance.

Indication of non-surgical management for acute limb ischemia

Acute Limb Ischemia (ALI) is a sudden decrease in limb perfusion that has a potential threat of life and limb viability. Although, surgical thrombectomy using an occlusion catheter (Fogarty catheter) has been traditionally performed as the standard approach for ALI, endovascular treatment (EVT) has recently been developed as an alternative to surgical revascularization. However, its indication remains unclear. We reviewed the indication of conventional treatments and introduced our original technique. There are several non-surgical treatments for ALI such as Percutaneous Aspiration Thrombectomy (PAT), Catheter-Directed Thrombolysis (CDT), angioplasty and stenting. PAT is effective for the patients with ALI in small vessels such as below-the-knee arteries. CDT is recommended for Rutherford grade I patients. Angioplasty and stent implantation, which is a well-established strategy in peripheral arterial disease, is applicable for the ALI patients in any Rutherford grade. We previously reported an endovascular technique using a guide extension catheter in the non-stenting zone for ALI, which is named “Temporary Endoluminal Bypass (TEB) technique”. This technique is based on the concept of a perfusion catheter and applied for a treatment of ALI. This technique is composed of 3 steps. First, we measure the lesion length. Second, we deliver the guide extension catheter to fully cover the lesion. Finally, we confirm the distal blood flow by angiography. Subsequently, urokinase (10,000 U/hr) is selectively administered to the vessel from the sheath. The endpoint of thrombolysis is determined by the achievement of antegrade blood flow after removal of the guide extension catheter. TEB technique is basically recommended for the ALI patients with Rutherford grades IIa and IIb. TEB technique may be an alternative treatment option for ALI although further investigation is needed.

Implementation of an Alert System for Acute Limb Ischemia in the Inpatient Setting: Success and Failures

Acute limb ischemia (ALI) most commonly occurs in outpatients, but the inpatient population is also at risk. Many inpatients are not able to elicit the usual symptoms of ALI and may have a delayed diagnosis resulting in poor outcomes. Our institution created a novel alert program to facilitate the rapid diagnosis and treatment of ALI in the inpatient population. All ALI alerts from October 2017 to December 2019 were collected from our institution’s paging records and analyzed for location, timing, and the need for intervention. Alerts undergoing vascular intervention were classified as urgent (within 8 hours from alert) or delayed (after 8 hours from alert). Time and location data were evaluated to determine patterns of usage and the true-positive rate of the system. From October 2017 to December 2019, there were 237 ALI alerts. Operative intervention was required in 27 patients (11.3%, positive predictive value). Of these, 11 patients (41%) required urgent surgery with a mean time to intervention of 4.1 ± 1.8 hours, and 16 (59%) alerts received a delayed intervention at a mean of 5.6 ± 8.0 days. Two patients ultimately required major amputation. More alerts came from intensive care units (ICUs) (67%) compared to non-ICU floors (33%); however, a higher number of non-ICU floor alerts (32%, 19/60) required intervention compared to ICU alerts (5%, 8/150). The highest number of ALI alerts were from the cardiology ICU (24.9%) and medical ICU (21.1%), followed by trauma surgery ICU (12.2%). The 3 hours after morning and evening nursing shift changes accounted for a disproportionate volume of alerts (47.3%). A total of 73 (30.6%) alert patients died during their admission. The median time to death was 2 days (range, 0-95 days), and in 22 cases death occurred less than 24 hours from time of alert. No deaths were directly related to ALI. The ALI alert system at our hospital demonstrates a low positive predictive value, which is consistent with the low threshold for initiating an alert. The increased frequency of alerts after nursing shift changes may indicate a discrepancy in the handoff between staff or decreased staffing ratios in the evenings. Given the large number of false alerts in the ICU setting, a review of the protocol in that context is warranted. Future work will assess the affect this alert system has on patient safety, patient outcomes, the development of alert fatigue, and the allocation of institutional resources.

Comparison of Ultrasound-Accelerated Versus Multi-hole Infusion Catheter-Directed Thrombolysis for the Treatment of Acute Limb Ischemia

Retrospective single-center review between 2006 and 2008 Thrombolysis of thrombosed native arteries and arterial bypasses was performed with Uni-Fuse multihole catheters (AngioDynamics, Latham, NY) in 69 cases and EKOS ultrasound-accelerated catheters (EKOS Corporation, Bothell, Wash) in 22 cases. All patients were initially treated with the power-pulse feature of an AngioJet catheter (Boston Scientific, Marlborough, Mass) administering 10 mg of alteplase (tissue plasminogen activator [tPA]) followed 20 minutes later by rheolytic catheter-directed thrombectomy. Residual thrombus was treated with either Uni-Fuse or EKOS catheters with tPA infused at 0.5 to 2.0 mg/h overnight. The mean duration of thrombolysis, mean volume of tPA, technical success, and complications were similar in both groups. The standard multihole infusion catheter demonstrates similar clinical safety and efficacy as the ultrasound-accelerated EKOS system to treat acute arterial limb ischemia.

Real-World Outcomes of EKOS Ultrasound-Enhanced Catheter-Directed Thrombolysis for Acute Limb Ischemia

Ultrasound-enhanced catheter-directed thrombolysis (UET) using the Ekosonic® Endovascular System device for acute, peripheral arterial ischemia has been purported in clinical trials to accelerate the fibrinolytic process to reduce treatment time and lytic dosage. We aim to describe outcomes of UET in a real-world clinical setting. We performed a retrospective review of all patients undergoing UET for acute limb ischemia at a single institution. Data collected included patient demographics, procedural details, and 30-day and 1-year outcomes. The primary endpoints for analysis were major adverse limb events (MALEs; reintervention and/or amputation) and mortality within 30-days and 1-year. Secondary endpoints included technical success, use of adjunctive therapies, and postoperative complications. A total of 32 patients (mean age 67.4±14.9years; 25% women) underwent UET for acute limb ischemia between 2014 and 2018. The Rutherford Acute Limb Ischemia Classification was Rutherford (R) 1 in 56.3%, R2a in 31.3%, and R2b in 12.5%. Etiology was thrombosis of native artery in 12.5% of patients, prosthetic bypass in 31.3%, autogenous bypass in 6.3%, and stented native vessel in 50.0%. Mean duration of thrombolytic therapy was 22.2±11.3hr, and mean tissue plasminogen activator dose was 24.5±15.3mg. MALEs occurred in 16.7% of patients within the first 30 days and 38.9% experienced a MALE by 1 year. Limb salvage at 30 days and 1 year was 93.8% and 87.5%, respectively. Ipsilateral reintervention was required in 12.5% of patients within 30days and 37.5% of patients within 1year. Overall mortality was 6.2% at 30 days and 13.5% at 1 year. In-line flow to the foot was re-established in 90.6% of patients, with a significant improvement in preoperative to postoperative ankle-brachial index (0.31±0.29 vs. 0.78±0.34, P<0.001) and number of patent tibial runoff vessels (1.31±1.20 vs. 1.96±0.86, P<0.001). There was no significant difference in revascularization success between occluded vessel types. All but one patient required adjunctive therapy such as further thromboaspiration, stenting, or balloon angioplasty. Major bleeding complications occurred in 3 patients (9.4%), including 1 intracranial hemorrhage (3.1%). UET with the EKOS device demonstrates acceptable real-world outcomes in the treatment of acute limb ischemia. UET is generally safe and effective at re-establishing in-line flow to yield high limb salvage rates. However, UET is associated with a high rate of reintervention. Further investigation is needed into specific predictors of limb salvage and need for reintervention, as well as cost-efficacy of this technology compared with that of traditional methods.

Analysis of the Safety and Efficacy of the Endovascular Treatment for Acute Limb Ischemia with Percutaneous Pharmacomechanical Thrombectomy Compared with Catheter-Directed Thrombolysis

To evaluate the rates of limb salvage, survival, and perioperative mortality in patients with acute limb ischemia (ALI) submitted to endovascular revascularization with pharmacomechanical thrombectomy (PMT) and catheter-directed thrombolysis (CDT). This was a retrospective consecutive cohort study of patients with ALI who were submitted to endovascular treatment with PMT or fibrinolysis at the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual (São Paulo, Brazil), between July 2015 and December 2018. The limb salvage rate and survival rate at 720days were analyzed in both the PMT (group 1) and CDT treatment (group 2), as well as the perioperative mortality rate (PMR) at 30days after surgery. One hundred twelve patients were admitted to the emergency department with ALI between July 2015 and December 2018. Seventeen patients diagnosed with Rutherford III irreversible ALI and 46 patients submitted to open surgery were excluded. Thus, 49 patients were submitted to endovascular surgery; 18 (36.7%) were classified into group 1, and 31 (63.3%) were classified into group 2. The clinical data were equal between the 2 groups, but there was a higher prevalence of thrombophilia in group 1 (3 cases; P<0.001). The limb salvage rate and the overall survival rate at 720days were similar between groups 1 and 2 (87.8% vs. 89.7%, P=0.78 and 84.7% vs. 69.2%, P=0.82, respectively). There was no statistical difference regarding secondary patency rates at 720days between groups 1 and 2 (group 1, 81.9% and group 2, 78.8%; P=0.66). The PMR was 16.7% (8 patients) within the first 30days. Group 2 had a higher overall mortality rate (OMR) (6 patients, 19.3%, P=0.03). Regarding the PMT group, there was a higher rate of complications such as myoglobinuria, hematuria, acute renal failure, and death in the subgroup of patients in whom there were performed more than 150 cycles/sec during the surgery (P < 0.001). In the present study, the PMT and CDT endovascular procedures had similar limb salvage, overall survival, and secondary patency rates. However, the OMR was higher in the CDT group. Another important finding was related to the number of cycles/sec performed in the PMT group, in whom patients with more than 150 cycles/sec have presented with higher rates of hematuria, myoglobinuria, acute renal failure, and death.

Comparative evaluation of the endovascular and surgical revascularization effectiveness for acute limb ischemia

The aim — to do comparative evaluation of the endovascular and surgical revascularization effectiveness in patients with acute limb ischemia, caused by thrombosis and embolism of lower limb arteries.Materials and methods. The study was performed based on a retrospective analysis of the results of treatment of 215 patients with acute limb ischemia caused by acute emboli and thrombosis of lower limb arteries or bypases. The main group included 108 patients who underwent endovascular interventions (intra‑arterial catheter‑directeded thrombolysis was performed in 72 % of patients, and endovascular thrombectomy was performed in 28 % of patients), the comparison group included 107 patients were performed surgical operations of thromboembolectomy or bypases for the purpose of revascularization.Results and discussion. In order to determine how the degree of ischemia affects technical success of endovascular and surgical interventions in patients with acute limb ischemia, patients were stratified according to severity of ischemia. The technical success of revascularization in patients with 1 or 2A degrees of ischemia was not significantly different between groups. In patients of the surgical group with ischemia 2B, the technical success rate of revascularization was significantly higher compared with endovascular, 83.6 % versus 71.9 % (p &lt; 0.05). The number of amputations in endovascular and surgical groups was not significantly different, 16.7 %, and 18.7 % (p &gt; 0.05).Conclusions. The severity of limb ischemia is the main factor that determines the results of treatment of acute limb ischemia, both with endovascular and surgical methods of revascularization. Patients with severe grade 2B ischemia require emergency restoration of blood circulation in the ischemic limb and surgical methods are the most appropriate treatment. In patients with moderately severe 1 and 2A ischemia, both surgical and endovascular revascularization methods can be effectively used.

PC098. Reassessing the Role of Fasciotomy After Revascularization of Nontraumatic Acute Lower Limb Ischemia

The use of fasciotomies to prevent complications of compartment syndrome after the treatment of acute limb ischemia is widespread; however, minimal objective data support this practice. We present a single-institution experience in which fasciotomies are not regularly performed after revascularization. Using International Classification of Diseases, Ninth Revision and Tenth Revision codes, we identified all patients presenting to UC Davis Medical Center between January 2003 and July 2018 with acute limb ischemia, excluding those with traumatic injuries. Primary outcomes were amputation and new motor deficit. In addition, we summarized our findings in those patients with and without fasciotomies, excluding those with grade III ischemia. We identified 275 limbs treated for acute limb ischemia. Of these, 22 had grade III ischemia and 253 had Rutherford grade I (52), grade IIa (92), or grade IIb (109) ischemia. Of these, 230 (91%) were successfully revascularized, whereas 23 had nonreconstructible disease (Table). The overall amputation rate was 8% (2.6% of revascularized limbs and 65% of nonreconstructible limbs). A total of 11 fasciotomies were performed in the successfully revascularized limbs. Of the 230 limbs with reconstructible disease, 135 limbs had grade I/IIa ischemia and 95 limbs had grade IIb ischemia; 134 of the 135 Rutherford grade I/IIa ischemic limbs did not undergo fasciotomy after revascularization. In this group, 102 limbs (76%) presented with ischemic symptoms >6 hours. Retained motor function after revascularization was seen in 95% of these limbs. New-onset footdrop occurred in 2 of 102 limbs (2%) with >6 hours of ischemic symptoms and none with <6 hours. In the 95 limbs with grade IIb ischemia (Fig), 65 had >6 hours of symptoms. Of these, 58 did not receive a fasciotomy, and 69% of these limbs had improved motor function, 14% had persistent motor deficit, and 7% were amputated. Of the seven receiving fasciotomy, 43% experienced improved motor function, whereas 14% had persistent footdrop, and there were no amputations. In the 30 limbs with <6 hours of ischemic symptoms, 27 did not have a fasciotomy, and 74% of these had improved motor function, 11% had persistent footdrop, and 4% were amputated. Of the three receiving fasciotomy, 67% had improved motor function, and there were no persistent motor deficits or amputations. Our experience demonstrates an acceptable amputation rate and low rate of new-onset motor dysfunction in salvageable limbs, thereby suggesting that fasciotomies may not always be necessary in patients who present with acute limb ischemia due to isolated arterial occlusion.TableOutcomes by Rutherford gradeRutherford INo fasciotomy (n = 48), No. (%)Fasciotomy (n = 0), No. (%)Prolonged ischemia (>6 hours)37 (77.1)0Preserved motor function46 (95.8)0Motor dysfunction1 (2.1)0Amputation00Death1 (2.1)0Rutherford IIaNo fasciotomy (n = 86), No. (%)Fasciotomy (n = 1), No. (%)Prolonged ischemia (>6 hours)65 (75.6)0Preserved motor function81 (94.2)0Motor dysfunction1 (1.2)0Amputation01Death4 (4.7)1Rutherford IIbNo fasciotomy (n = 85), No. (%)Fasciotomy (n = 10), No. (%)Prolonged ischemia (>6 hours)58 (68.2)7 (70.0)Improved motor function60 (70.6)5 (50.0)Motor dysfunction11 (13.9)1 (10.0)Amputation5 (5.9)0Death9 (10.6)4 (40.0)Excludes limbs with nonreconstructable disease. Open table in a new tab

IP225. Real-World Outcomes of EKOS Ultrasound-Enhanced Catheter-Directed Thrombolysis for Acute Limb Ischemia

Ultrasound-enhanced catheter-directed thrombolysis (UET) using the EKOS device (EKOS Corporation, Bothell, Wash) for acute peripheral artery ischemia has been purported in clinical trials to accelerate the fibrinolytic process to reduce treatment time and lytic dosage. However, UET performance in a real-world clinical setting has thus far been inadequately described. We performed a retrospective review of all patients undergoing UET for acute limb ischemia at a single institution during a 5-year period. Data collected included patients' demographics, procedural details, and 30-day and 1-year outcomes. Primary outcomes were major bleeding events, limb salvage, and mortality. We identified 32 patients (mean age, 67.4 ± 14.9 years; 25% female) who underwent UET for acute limb ischemia between 2014 and 2018. At presentation, 43.8% were therapeutically anticoagulated. Rutherford acute limb ischemia classification was I in 56.3%, IIa in 25.0%, and IIb in 18.8%. Etiology was thrombosis of native artery in 12.5% of patients, infrainguinal prosthetic bypass in 31.3%, infrainguinal autogenous bypass in 6.3%, and stented native vessel in 50.0%. Mean duration of thrombolytic therapy was 22.2 ± 11.3 hours, and mean tissue plasminogen activator dose was 24.5 ± 15.3 mg. In-line flow to the foot was re-established in 90.6% of patients with a significant improvement in preoperative to postoperative ankle-brachial index (0.31 ± 0.29 vs 0.78 ± 0.34; P < .001) and number of patent tibial runoff vessels (1.31 ± 1.20 vs 1.96 ± 0.86; P < .001; Fig). There was no significant difference in revascularization success between occluded vessel types: native vessel, 75% success; stented vessel, 93.8%, autogenous bypass, 100%, and prosthetic bypass, 90% (P = .48). Major bleeding complications occurred in three patients (9.4%), including two intracranial hemorrhages (6.3%). Limb salvage at 30 days and 1 year was 93.8% and 87.5%, respectively. Ipsilateral reintervention was required in 37.5% of patients within 1 year. Overall mortality was 6.2% at 30 days and 13.5% at 1 year, and mortality was significantly higher in patients with higher Rutherford class (P = .049). UET with the EKOS device demonstrates acceptable real-world outcomes in the treatment of acute limb ischemia. UET is generally safe, with a low rate of associated hemorrhagic complications, and is effective at re-establishing in-line flow to yield high limb salvage rates. However, UET is associated with a high rate of reintervention within 1 year. Further investigation is needed into specific predictors of limb salvage and need for reintervention as well as cost-efficacy of this technology compared with traditional methods.

Does the new vascular management of acute limb ischemia have effective results with lower treatment costs.

Aim To compare hospital costs of acute limb ischemia treatment in two periods of time and to show evidence of long-term repercussions on reducing costs during successful treatment. Methods Retrospective analysis of data obtained from 100 patients' medical history in the period 2000-2016 at the Clinic of Vascular Surgery Sarajevo: group A - 60 patients with acute limb ischemia in the period 2005-2016 and group B - 40 patients with acute limb ischemia (ALI) in the period 2000-2005. From 2000 to 2005 conservative treatment method was used, invasive diagnostic and surgical procedures were often delayed for a shorter or longer period of time. During the period from 2005 to 2016, the management model and safe practice included emergency diagnostic procedures, colour-Doppler, arteriography, emergency surgery (embolectomy by Fogharty and if necessary, vascular by-pass). Results Better health service for the patients with acute limb ischemia was offered in the period 2005-2016, which relied on proven medical treatment trends. The largest share of the total costs of each patient included costs of hospital bed with significant difference between the period 2005-2016 and 2000-2005, mean of 1398.71 KM and 2480.45KM, respectively (p<0.0001), indicating rationalization of time that patients spend at the Vascular Clinic. Conclusion This trend of money/fund savings is an example of good practice, effectiveness and efficiency in the treatment of ALI and as such was used in patients with other vascular diseases.

Temporal trends and hospital costs associated with an endovascular-first approach for acute limb ischemia

ObjectiveRecent studies suggest similar perioperative outcomes for endovascular and open surgical management of acute limb ischemia (ALI). We sought to describe temporal trends, patient factors, and hospital costs associated with contemporary ALI management. MethodsWe used the weighted National Inpatient Sample to estimate primary ALI cases requiring open or endovascular intervention (2005-2014). We used multivariable regression models to examine temporal trends, patient factors, and hospital costs associated with endovascular-first vs open-first management. ResultsOf 116,451 admissions for ALI during the study period, 35.2% were treated by an endovascular-first approach. The percentage of admissions managed with an endovascular-first approach increased over time (P < .001). Independent predictors of endovascular-first management included younger age, male sex, renal insufficiency, and more recent calendar year of admission (P ≤ .02), whereas patients who underwent fasciotomy, those with Medicaid, and those admitted on a weekend were more likely to undergo open-first management (P ≤ .02). Endovascular-first management had higher mean hospital costs than open-first management ($29,719 vs $26,193; P < .001). After adjustment for patient, hospital, and admission characteristics, there was an increase of $981 in treatment costs per year in the endovascular-first group (95% confidence interval [CI], $571-$1392; P < .001), whereas the costs associated with an open-first approach remained relatively stable over time ($10 per year; 95% CI, −$295 to $315; P = .95; P < .001 for interaction). The risk-adjusted odds of in-hospital major amputation was similar in both groups (adjusted odds ratio, 0.99; 95% CI, 0.85-1.15; P = .88). ConclusionsUse of an endovascular-first approach for the treatment of ALI has significantly increased over time. Although major amputation rates are similar for both approaches, the costs associated with an endovascular-first approach are increasing over time, whereas the costs of open surgery have remained stable. The cost-effectiveness of modern ALI management warrants further investigation.