Revascularization of a specific angiosome for limb salvage: does the target artery matter?

Abstract Background To compare clinical outcomes and technical success when direct versus indirect revascularization was achieved after endovascular technique for critical limb ischemia patients with isolated below-the-knee lesions. Fifty patients were included, 34 male and 16 female, their age from 49 to 77 years (mean 63 ±16). All patients were subjected to infra-genicular angioplasty and divided into direct 28 (31 limbs) and indirect groups 22 (24 limbs). Antegrade approach through ipsilateral CFA was used in 48 patients, while retrograde approach through tibiopedal access was used in 2 patients. Diagnostic angiography was done for all cases and duplex ultrasound was used for follow-up. Results One hundred thirty-two lesions were encountered, 46 in the ATA, 43 in PTA, 29 in peroneal artery, and 19 in dorsalis pedis artery. Transluminal approach was done in 47 limbs while subintimal cross was used in 8 limbs. After 1 year follow-up, AFS was 75% in the direct group and 67% in the indirect group. Freedom from MALE was 65% in the direct group and 55% in the indirect group. Freedom from MA was 86% in the direct group and 75% in the indirect group. Conclusion When there is a choice of target artery for revascularization, preference should be given to the artery directly feeding the wound’s angiosome.

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COVID-19 diagnosis in a patient with critical limb ischemia: complications and clinical outcomes

Jornal Vascular Brasileiro ◽

10.1590/1677-5449.200071 ◽

2020 ◽

Vol 19 ◽

Author(s):

Rafael de Athayde Soares ◽

Rafael Salem Vedovello ◽

Samanta Christine Guedes de Medeiros ◽

Celso Zaffani Nunes ◽

Carlos Alberto Sian ◽

...

Keyword(s):

Duplex Ultrasound ◽

Limb Ischemia ◽

Peroneal Artery ◽

Rt Pcr ◽

Technical Success ◽

Chain Reaction ◽

Systemic Arterial Hypertension ◽

Below The Knee ◽

Appropriate Treatment ◽

Polymerase Chain

Abstract A 67-year-old male diabetic patient with systemic arterial hypertension was admitted to the emergency department with a necrotic ulcer in the left external malleolus and no palpable popliteal or pedal pulses. Arterial Duplex ultrasound identified femoropopliteal occlusion, with popliteal refilling below the knee and a patent peroneal artery. An endovascular procedure was performed, requiring retrograde access to the popliteal artery to re-establish blood flow and deploy a popliteal stent. Technical success was achieved and the patient underwent debridement of the wound. Two days later, about 48 hours after the operation, the patient began to exhibit respiratory symptoms, with coughing and dyspnea. He immediately underwent a chest CT that identified ground glass opacities, the crazy-paving pattern, and bilateral air bronchogram in the lungs. A reverse transcription – polymerase chain reaction (RT-PCR) test was positive for SARS-Cov-2. The patient was moved to an intensive care unit and put on mechanical ventilation. Both hydroxychloroquine and azithromycin were administered. Despite appropriate treatment, the patient died 4 days after he was diagnosed with COVID-19.

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Antegrade vs Crossover Femoral Artery Access in the Endovascular Treatment of Isolated Below-the-Knee Lesions in Patients With Critical Limb Ischemia

Journal of Endovascular Therapy ◽

10.1177/1526602817701251 ◽

2017 ◽

Vol 24 (3) ◽

pp. 331-336 ◽

Cited By ~ 3

Author(s):

Yukun Li ◽

Ali Esmail ◽

Konstantinos P. Donas ◽

Georgios Pitoulias ◽

Giovanni Torsello ◽

...

Keyword(s):

Endovascular Treatment ◽

Success Rate ◽

Femoral Artery ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Technical Success ◽

Femoral Access ◽

Technical Success Rate ◽

Below The Knee ◽

Antegrade Approach

Purpose: To evaluate the safety and effectiveness of antegrade vs crossover femoral artery access in the endovascular treatment of isolated below-the-knee (BTK) lesions in patients with critical limb ischemia (CLI). Methods: Between January 2014 and December 2015, 224 high-risk patients (mean age 75.8±9.8 years; 151 men) with CLI underwent infragenicular interventions on 292 crural vessels in 3 European vascular centers. All patients had isolated TransAtlantic Inter-Society Consensus (TASC) C (n=26) or D (n=198) BTK lesions. Primary endpoints were freedom from access-related complications and technical success comparing the antegrade vs crossover access groups. Results: Balloon angioplasty was the most used treatment modality (169 vessels, 75.4%). The technical success rate was 88.4% in the entire cohort and 88.0% in the antegrade group vs 90.4% in the crossover group (p>0.99). In all patients, the technical success rate was higher for stenotic lesions (100%) vs occlusions (85.5%, p=0.002) and in patients with TASC C BTK lesions (100%) vs TASC D (86.9%, p=0.033). The overall freedom from access-related complications was 97.8%: 99% in the antegrade group and 90.6% in the crossover group (p=0.022). Larger sheath size (5/6-F vs 4-F) was associated with a significantly higher risk for access-related complications (7.1% vs 1.1%, respectively; p=0.047). Conclusion: The present multicenter study showed high technical success and a low incidence of access-related complications in the treatment of isolated BTK lesions using either antegrade or crossover femoral access. The antegrade approach with the use of a 4-F system seems to have a significantly lower rate of access-related complications.

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Duplex Ultrasound—Guided Femoropopliteal Angioplasty: Initial and 12-Month Results from a Case Controlled Study

Journal of Endovascular Therapy ◽

10.1177/152660280200900622 ◽

2002 ◽

Vol 9 (6) ◽

pp. 873-881 ◽

Cited By ~ 4

Author(s):

Ramazanali Ahmadi ◽

Ara Ugurluoglu ◽

Martin Schillinger ◽

Reinhold Katzenschlager ◽

Schila Sabeti ◽

...

Keyword(s):

High Risk ◽

Ankle Brachial Index ◽

Duplex Ultrasound ◽

Duplex Sonography ◽

Controlled Study ◽

Technical Success ◽

Ultrasound Guided ◽

Procedural Complications ◽

Feasible Alternative

Purpose: To evaluate initial technical success, procedural complications, and 12-month patency of duplex-guided angioplasty compared to conventional fluoroscopically-guided procedures. Methods: One hundred four patients (65 men; mean age 69 years) who underwent duplex-guided femoropopliteal angioplasty were compared to 104 patients undergoing fluoroscopically-guide procedures who were matched for age, sex, baseline ankle-brachial index (ABI), and length and grade of lesion. Patients were followed for 12 months, and restenosis was assessed by ABI and duplex sonography. Results: Technical success was achieved in 88 (84.6%) patients from the duplex-guided group and in 102 (98.1%) control patients (p=0.001). Periprocedural complications occurred in 12.5% (n=13) and 18.3% (n=19), respectively (p=0.4). Contrast-induced transient renal impairment was observed in 7 (6.7%) patients in the fluoroscopic group. One hundred (96.1%) patients in the duplex and 102 (98.1%) patients in the fluoroscopic group completed the 12-month follow-up. Restenosis was found in 35 (39.8%) patients of the duplex group and in 38 (37.2%) patients of the fluoroscopic group (p=0.8). Conclusions: Technical success of duplex-guided procedures was significantly lower compared to fluoroscopic angioplasty; complications and 12-month patency were similar with both techniques. Duplex-guided angioplasty may be a feasible alternative, particularly for patients at high risk for contrast-induced complications.

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Prospective Single-Arm Trial of Endovascular Mechanical Debulking as Initial Therapy in Patients With Acute and Subacute Lower Limb Ischemia: One-Year Outcomes

Journal of Endovascular Therapy ◽

10.1177/1526602819840697 ◽

2019 ◽

Vol 26 (3) ◽

pp. 291-301 ◽

Cited By ~ 3

Author(s):

Miroslav Bulvas ◽

Zuzana Sommerová ◽

Ivan Vaněk ◽

Jiří Weiss

Keyword(s):

Limb Ischemia ◽

Initial Therapy ◽

Exclusion Criterion ◽

Secondary Patency ◽

Primary Therapy ◽

Technical Success ◽

Free Survival ◽

The Mean ◽

One Year

Purpose: To report the results of a prospective, single-arm study to establish whether the initial treatment of acute or subacute limb ischemia (ALI and SLI, respectively) can be accomplished successfully using endovascular mechanical debulking of the target vessels to avoid the risks associated with thrombolysis and/or open surgery. Materials and Methods: From April 2009 to April 2015, 316 consecutive patients (mean age 70.9±12 years; 184 men) with ALI (202, 63.9%) or SLI (114, 36.1%) were enrolled; the only exclusion criterion was irreversible ischemia. The ALI group included 146 (72.3%) participants with category IIb ischemia and 56 (27.7%) with category IIa. Critical limb ischemia was diagnosed in 74 (64.9%) of the 114 patients with SLI. Target occlusions of thrombotic (n=256) or embolic (n=60) origin were located in the femoropopliteal segment (n=231), prosthetic or venous femoropopliteal bypass grafts (n=75), and the aortoiliac segment (n=35). The mean occlusion length was 22.9±14.8 cm. Results: The overall technical success (residual stenosis ≤30%) was 100% after debulking and adjunctive techniques (aspiration, dilation, stenting) at the level of the target lesions. No open surgical or thrombolytic modalities were necessary to bypass or recanalize the target vessels, and no death occurred in association with target occlusion therapy. Additional infrapopliteal interventions were performed in 195 (61.7%) patients (adjunctive thrombolysis in 29) to treat acute, subacute, and chronic lesions. Minor complications directly related to the debulking procedure occurred in 26 (8.2%) patients. Serious complications occurred in 11 (3.5%) patients, including hemorrhage in 8 (2.5%) patients (associated with infrapopliteal thrombolysis in 5). At 30 days, primary and secondary patency rates were 94.3% and 97.2%, respectively; mortality was 0.3% (1 fatal intracranial hemorrhage after adjunctive thrombolysis). Of 229 patients eligible for 1-year follow-up, amputation-free survival was estimated to be 87.4% in 199 patients with available data. Conclusion: In this all-comers study, mechanical debulking with the Rotarex alone or with adjunctive techniques is feasible as a primary therapy for occluded supratibial vessels in patients with ALI or SLI.

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Angioplasty and Elective Stenting of De Novo versus Recurrent Femoropopliteal Lesions: 1-Year Follow-up

Journal of Endovascular Therapy ◽

10.1177/152660280301000219 ◽

2003 ◽

Vol 10 (2) ◽

pp. 288-297 ◽

Cited By ~ 22

Author(s):

Martin Schillinger ◽

Wolfgang Mlekusch ◽

Markus Haumer ◽

Schila Sabeti ◽

Ramazanali Ahmadi ◽

...

Keyword(s):

Stent Implantation ◽

De Novo ◽

Limb Ischemia ◽

Duplex Sonography ◽

Transluminal Angioplasty ◽

Technical Success ◽

Color Duplex Sonography ◽

Adjusted Risk ◽

Percutaneous Transluminal

Purpose: To investigate patency rates after percutaneous transluminal angioplasty (PTA) and PTA plus elective stenting in de novo versus recurrent femoropopliteal lesions. Methods: The data were collected from a prospective registry including 533 consecutive patients (284 men; median age 71 years, interquartile range [IQR] 72–78) with severe claudication (n=387) or critical limb ischemia (n = 146) who underwent femoropopliteal percutaneous interventions during a 36-month period. PTA was used to treat 357 de novo and 99 recurrent lesions; PTA plus elective stent implantation was performed in 58 de novo and 19 recurrent lesions. Patients were followed for a median 12 months (IQR 7–14) using color duplex sonography. Rates of restenosis (≥50%) were compared by multivariate analysis. Results: Overall primary technical success was achieved in 517 (97%) patients; 31 (6%) periprocedural complications were encountered. Restenosis occurred in 213 (40%) patients after a median 6 months (IQR 4–7). Twelve-month patency after PTA was 61% in de novo and 33% in recurrent lesions (p<0.0001). Patients with recurrent lesions had a 2.3-fold increased adjusted risk for restenosis after PTA (95% confidence interval 1.7 to 3.2). Twelve-month patency after stenting was 58% in de novo and 52% in recurrent lesions (p=0.9). In patients with de novo lesions, patency rates after PTA and stent were similar (p=0.8); however, in patients with recurrent lesions, elective stenting performed better (p=0.05). Conclusions: Recurrent stenosis after prior femoropopliteal balloon angioplasty is an independent risk factor for restenosis; these lesions exhibit disappointing patency after repeated PTA. Stent implantation may improve intermediate-term results in these patients.

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Stenting versus balloon angioplasty alone in patients with below-the-knee disease: A propensity score-matched analysis

PLoS ONE ◽

10.1371/journal.pone.0251755 ◽

2021 ◽

Vol 16 (6) ◽

pp. e0251755

Author(s):

Jihun Ahn ◽

JinSu Byeon ◽

Byoung Geol Choi ◽

Se Yeon Choi ◽

Jae Kyeong Byun ◽

...

Keyword(s):

Propensity Score ◽

Clinical Outcomes ◽

Balloon Angioplasty ◽

Limb Ischemia ◽

Primary Patency ◽

Secondary Patency ◽

Stent Group ◽

Below The Knee ◽

Procedural Success

Percutaneous transluminal angioplasty (PTA) is considered an effective treatment in patients with critical limb ischemia (CLI). However, the long-term durability of below-the-knee (BTK) PTA is known to be limited. This study sought to compare the 1-year clinical outcomes following stenting versus balloon angioplasty alone in BTK lesions. This study included 357 consecutive patients (400 limbs, 697 lesions) with BTK lesions who underwent PTA from September 2010 to December 2016. All enrolled patients were treated either by stenting (stent group; 111 limbs of 102 patients) or plain old balloon angioplasty (POBA group; 289 limbs of 255 patients). Stent group includes both primary and provisional stenting. Angiographic outcomes, procedural success, complications, and clinical outcomes were compared between the two groups up to 1 year. After propensity score matching (PSM) analysis, 56 pairs were generated, and the baseline and angiographic characteristics were balanced. The procedural success and complications were similar between the two groups; however, the incidence of procedure-related perforation was higher in the POBA group than in the stenting group [5(11.9%) vs.1 (0.9%), P = 0.009]. Six- to 9-month computed tomography or angiographic follow-up showed similar incidences of binary restenosis, primary patency, and secondary patency. In the 1-year clinical follow-up, there were similar incidences of individual hard endpoints, including mortality, myocardial infarction, limb salvage, and amputation rate, with the exception of target extremity revascularization (TER), which tended to be higher in the stenting group than in the POBA group [21 (20.8%) vs. 11 (10.9%), P = 0.054]. Although there was a trend toward a higher incidence of TER risk in the stenting group, stent implantation, particularly in bail-out stenting seemed to have acceptable 1-year safety and efficacy compared to POBA alone in patients undergoing BTK PTA.

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Tibiopedal Access for Crossing of Infrainguinal Artery Occlusions

Journal of Endovascular Therapy ◽

10.1177/1526602816664768 ◽

2016 ◽

Vol 23 (6) ◽

pp. 839-846 ◽

Cited By ~ 35

Author(s):

Craig M. Walker ◽

Jihad Mustapha ◽

Thomas Zeller ◽

Andrej Schmidt ◽

Miguel Montero-Baker ◽

...

Keyword(s):

Limb Ischemia ◽

Technical Success ◽

Surgical Revascularization ◽

Access Site ◽

Chronic Total Occlusions ◽

Multicenter Observational Study ◽

The World ◽

Prospective Multicenter Observational Study ◽

Vessel Thrombosis

Purpose: To report a prospective, multicenter, observational study ( ClinicalTrials.gov identifier NCT01609621) of the safety and effectiveness of tibiopedal access and retrograde crossing in the treatment of infrainguinal chronic total occlusions (CTOs). Methods: Twelve sites around the world prospectively enrolled 197 patients (mean age 71±11 years, range 41-93; 129 men) from May 2012 to July 2013 who met the inclusion criterion of at least one CTO for which a retrograde crossing procedure was planned or became necessary. The population consisted of 64 (32.5%) claudicants (Rutherford categories 2/3) and 133 (67.5%) patients with critical limb ischemia (Rutherford category ≥4). A primary antegrade attempt to cross had been made prior to the tibiopedal attempt in 132 (67.0%) cases. Techniques used for access, retrograde lesion crossing, and treatment were at the operator’s discretion. Follow-up data were obtained 30 days after the procedure. Results: Technical tibiopedal access success was achieved in 184 (93.4%) of 197 patients and technical occlusion crossing success in 157 (85.3%) of the 184 successful tibial accesses. Failed access attempts were more common in women (9 of 13 failures). The rate of successful crossing was roughly equivalent between sexes [84.7% (50/59) women compared to 85.6% (107/125) men]. Technical success did not differ significantly based on a prior failed antegrade attempt: the access success rate was 92.4% (122/132) after a failed antegrade access vs 95.4% (62/65) in those with a primary tibiopedal attempt (p=0.55). Similarly, crossing success was achieved in 82.8% (101/122) after a failed antegrade access vs 90.3% (56/62) for patients with no prior antegrade attempt (p=0.19). Minor complications related to the access site occurred in 11 (5.6%) cases; no patient had access vessel thrombosis, compartment syndrome, or surgical revascularization. Conclusion: Tibiopedal access appears to be safe and can be used effectively for the crossing of infrainguinal lesions in patients with severe lower limb ischemia.

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Non-traumatic Dorsalis Pedis Artery Aneurysm

Journal for Vascular Ultrasound ◽

10.1177/1544316720960571 ◽

2020 ◽

Vol 44 (4) ◽

pp. 200-202

Author(s):

Janet Wicander

Keyword(s):

Artery Aneurysm ◽

Duplex Ultrasound ◽

Vascular Surgeon ◽

Color Flow ◽

Case Presentation ◽

Dorsalis Pedis Artery ◽

Dorsal Aspect ◽

Patient Reported ◽

Good Flow

A true dorsalis pedis artery aneurysm is a very rare find. This is a case presentation of a patient with an asymptomatic non-traumatic dorsalis pedis artery aneurysm. A 49-year-old man was referred to the vascular lab for evaluation of an asymptomatic non-traumatic pulsatile lump on the dorsal aspect of his left foot. The patient reported that the lump had been present for at least 4 years. Color flow duplex ultrasound was used to evaluate the lump. Color flow duplex ultrasound examination of the lump demonstrated a dilatation of the dorsalis pedis artery, measuring approximately 1.05 cm by 1.35 cm. Mural thrombus is noted in gray scale image. Normal Doppler flow was noted in the dorsalis pedis artery, proximal, and distal to the aneurysm. The patient was referred to a vascular surgeon. Subsequently, he underwent a lower extremity arteriogram confirming the diagnosis of a dorsalis pedis artery aneurysm, with good distal blood flow to the toes. The patient underwent resection of the dorsalis pedis artery aneurysm. Reverse great saphenous vein was used as an interposition graft. Follow-up graft scans demonstrated good flow in the graft and in the native artery, distal to the graft. True dorsalis pedis artery aneurysms are very rare finding. When left untreated, the patient is at risk for embolization to the digits. Color flow Doppler is a very useful tool in diagnosing and assessing these aneurysms.

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Post-Thrombotic Syndrome after Total Hip or Knee Arthroplasty: Incidence in Patients with Asymptomatic Deep Venous Thrombosis

Journal of Orthopaedic Surgery ◽

10.1177/230949900501300202 ◽

2005 ◽

Vol 13 (2) ◽

pp. 113-119 ◽

Cited By ~ 31

Author(s):

OS Schindler ◽

R Dalziel

Keyword(s):

Venous Thrombosis ◽

Deep Venous Thrombosis ◽

Knee Arthroplasty ◽

Duplex Ultrasound ◽

Considerable Proportion ◽

Total Hip ◽

Post Thrombotic Syndrome ◽

Below The Knee ◽

Total Knee

Purpose. To measure the risk of developing signs of post-thrombotic syndrome 15 to 24 months after total hip or knee arthroplasty in patients with asymptomatic deep venous thrombosis (DVT). Methods. A total of 85 total knee arthroplasty patients and 47 total hip arthroplasty patients were postoperatively screened for asymptomatic DVT using colour duplex ultrasound. Results. The rate of asymptomatic DVT was 37.6% (n=32) in knee patients and 34.0% (n=16) in hip patients. All 32 DVT cases in the knee group had thrombi located below the knee, whereas 6 of the 16 DVT cases in the hip group had thrombi located above the knee, the remaining 10 were below the knee. Patients with proximal thrombi were treated with warfarin for 3 months, whereas patients with distal DVT received 300 mg aspirin daily for the same period. All DVT cases were monitored for up to 12 weeks using repeated colour duplex scans. Signs of thrombus resolution were present at around 6 weeks (range, 4–12 weeks). Clot propagation was observed in 3 cases. In a mean of postoperative 18 months (range, 15–24 months), 28 of the 32 knee patients with asymptomatic DVT were available for follow-up: 11 had transient calf and ankle swelling, 6 had persistent oedema, and the remaining 11 were symptom free. 14 of the 16 hip patients with asymptomatic DVT were available for follow-up: 6 had transient calf and ankle swelling, 4 had persistent oedema, and 4 remained symptom free. 17 patients reported ongoing problems and were re-examined. Signs of mild-to-moderate post-thrombotic syndrome were recorded in 4 knee patients and 3 hip patients. Conclusions. Patients with above-knee DVT were much more likely to have post-thrombotic syndrome. Despite thromboprophylaxis with low-molecular-weight heparin, asymptomatic DVT is common after total joint arthroplasty and is responsible for the development of post-thrombotic venous insufficiency and post-thrombotic syndrome in a considerable proportion of patients. Once symptomatic or asymptomatic DVT is established, treatment appears incapable of preventing the occurrence of post-thrombotic syndrome, especially in cases of above-knee DVT. Efforts should hence concentrate on combating DVT propagation and improving DVT prevention.

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Six-Month Freedom From Amputation Rates and Quality of Life Following Tibial and Pedal Endovascular Revascularization for Critical Limb Ischemia

Vascular and Endovascular Surgery ◽

10.1177/1538574418823378 ◽

2019 ◽

Vol 53 (3) ◽

pp. 212-215 ◽

Cited By ~ 1

Author(s):

Anahita Dua ◽

Kara A. Rothenberg ◽

Jisun J. Lee ◽

Rebecca Gologorsky ◽

Sapan S. Desai

Keyword(s):

Quality Of Life ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Major Amputation ◽

Technical Success ◽

Single Institution ◽

Disease Pattern ◽

Angioplasty And Stenting

Objective: Patients with critical limb ischemia (CLI) and gangrene have a 10% to 38% rate of major amputation at 6 months. The purpose of this study is to report short- and mid-term major and minor amputation rates for patients who underwent tibial and pedal revascularization in addition to quality-of-life (QoL) scores. Methods: All patients who presented to a single institution with CLI (defined as rest pain or nonhealing wounds) and underwent antegrade or retrograde tibial access, atherectomy and angioplasty of the tibial circulation, and angioplasty of pedal circulation (antegrade or retrograde) from June 2016 to September 2017 were included. The Stark QoL questionnaire was used at each visit. Patients were scored at 1, 3, and 6 months postprocedure. Amputation rates were recorded. Results: Forty-two patients with CLI and gangrene underwent 57 peripheral interventions for limb salvage between June 2016 and September 2017. Thirty-two limbs had dry gangrene along the dorsalis pedis angiosome, 14 limbs had dry gangrene along the posterior tibial angiogram, and 11 limbs had a combined disease pattern. Twelve limbs underwent angioplasty of the superficial femoral artery (SFA), 18 limbs underwent angioplasty and stenting of the SFA, and 14 limbs underwent atherectomy, angioplasty, and stenting of the SFA. All patients had 1 or 2 tibial vessel runoff and high-grade stenosis of the pedal circulation. Immediate technical success defined as 3-vessel outflow to the foot occurred in 49 limbs (86%) with zero 30-day complications (30-day readmission, major amputation, or sepsis). Major amputation rate at 1, 3, and 6 months was 0%, 2%, and 4%, respectively. Patient satisfaction in terms of QoL increased over the 6-month follow-up period. Conclusion: Aggressive tibial and pedal revascularization may improve freedom from minor and major amputation at 6 months and may be associated with a short- and mid-term higher QoL.

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