Endovascular Treatment Options of Acute Limb Ischemia

Acute limb ischemia is still the most frequent cause of major limb loss. Timely and fast revascularization is the key for limb salvage and patient survival. Large randomized trials showed equivalency of surgical and endovascular revascularization by means of local lysis with urokinase (TOPAS, STILE). New lytic agents and their modified application such as via a pulse spray catheter or combined with an ultrasound catheter and the combination with glycoprotein IIb/IIIa receptor antagonists have increased the efficacy and speed of thrombolysis. Recently, mechanical thrombectomy devices have become more widespread because intervention time and bleeding complications can be reduced. This review article summarizes the clinical presentation of and the treatment options for acute arterial occlusive disease caused either by embolism or local thrombosis.

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Abstract 17605: Cost-Effectiveness of Contemporary Endovascular Treatment Compared to Open Surgical Revascularization for Cardioembolic Acute Limb Ischemia

Circulation ◽

10.1161/circ.132.suppl_3.17605 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Elizabeth A Genovese ◽

Kenneth J Smith ◽

Neal R Barshes ◽

Michel S Makaroun ◽

Donald T Baril

Keyword(s):

Mortality Rate ◽

Endovascular Treatment ◽

Cost Effective ◽

Limb Ischemia ◽

Morbidity And Mortality ◽

Adverse Event Rate ◽

Parameter Estimates ◽

Acute Limb Ischemia ◽

Technical Success ◽

Life Years

Introduction: Treatment of acute limb ischemia (ALI) has a high morbidity and mortality given patients’ multiple comorbidities, poor physiologic reserve, and the need for emergent intervention. Traditionally ALI of embolic origin has been treated with open revascularization (OR), however with increasing experience with thrombolytic therapy and adjuvant techniques, endovascular revascularization (ER) for ALI has become a more common treatment due to the lower associated morbidity and mortality. Hypothesis: Although associated with higher initial costs and lower technical success rates, ER will be cost effective given the decreased adverse event rate and mortality in a frail patient population. Methods: A Markov state-transition model was created to simulate patient oriented outcomes, including technical success, adverse events, limb salvage, discharge facility and quality adjusted life years (QALY) for patients presenting with Rutherford Classification I/IIa/IIb ALI secondary to cardiac embolism. A societal perspective was assumed with a 10-year time horizon. Parameter estimates were derived from published literature and primary data of cardioembolic ALI patients treated at our institution from 2005-2011 with either ER or OR. Costs were adjusted to 2013 U.S. dollars. Results: In the model, OR was technically successful in 87% patients, with a $23,881 cost for the initial hospitalization and a 11.5% perioperative mortality rate; ER was technically successful in 71% of patients, with a $39,619 initial cost, and a 4% mortality rate. At 10 years, the ER strategy cost $92,659/QALY gained compared to OR. Sensitivity analyses demonstrated that ER was favorable at a willingness to pay (WTP) threshold of $100,000/QALY when ER technical success was >70%, initial ER hospitalization cost was <$41,052 or if OR mortality was >10%. At a WTP of $50,000/QALY, ER was cost effective if technical success reached 79%, if ER cost was <$31,287 or if OR mortality was >23%. Conclusions: Contemporary endovascular treatment of cardioembolic ALI carries a greater cost compared to open revascularization, however it is associated with a decreased mortality rate. ER is potentially cost-effective in patients who are at high risk of post-operative mortality following OR.

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

Annals of Vascular Surgery ◽

10.1016/j.avsg.2019.11.038 ◽

2020 ◽

Vol 66 ◽

pp. 470-478

Author(s):

Rafael de Athayde Soares ◽

Marcelo Fernando Matielo ◽

Francisco Cardoso Brochado Neto ◽

Bruno Vinícius Pereira de Carvalho ◽

Roberto Sacilotto

Keyword(s):

Endovascular Treatment ◽

Limb Ischemia ◽

Acute Limb Ischemia ◽

Safety And Efficacy ◽

Catheter Directed Thrombolysis

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Endovascular treatment of acute limb ischemia and proximal deep vein thrombosis using rotational thrombectomy: A review of published literature

Cardiovascular Revascularization Medicine ◽

10.1016/j.carrev.2013.08.005 ◽

2013 ◽

Vol 14 (6) ◽

pp. 343-348 ◽

Cited By ~ 16

Author(s):

Michael Lichtenberg ◽

Friedrich-Wilhelm Stahlhoff ◽

Dirk Boese

Keyword(s):

Deep Vein Thrombosis ◽

Endovascular Treatment ◽

Limb Ischemia ◽

Proximal Deep Vein Thrombosis ◽

Acute Limb Ischemia ◽

Vein Thrombosis ◽

Rotational Thrombectomy ◽

Deep Vein

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Bleeding complications at the access sites during catheter directed thrombolysis for acute limb ischaemia: Mini review

10.29328/journal.avm.1001014 ◽

2021 ◽

Vol 5 (1) ◽

pp. 001-003

Author(s):

Noory Elias ◽

Böhme Tanja ◽

Beschorner Ulrich ◽

Zeller Thomas

Keyword(s):

Treatment Options ◽

Limb Ischemia ◽

Lower Limbs ◽

Bleeding Complications ◽

Limb Ischaemia ◽

Acute Limb Ischemia ◽

Access Site ◽

Catheter Directed Thrombolysis ◽

Acute Limb Ischaemia ◽

Surgical Bypass

Acute and subacute ischemia of the lower limbs represents a major emergency with a high in-hospital mortality, complication, and leg amputation rates. Treatment options for acute limb ischemia include systemic anticoagulation, followed by various catheter based options including infusion of fibrinolytic agents (pharmacological thrombolysis), pharmacomechanical thrombolysis, catheter-mediated thrombus aspiration, mechanical thrombectomy, and any combination of the above or open surgical intervention (thromboembolectomy or surgical bypass). Minor and major bleeding complication during catheter directed thrombolysis (CDT) especially at access site are frequent. Bleeding complications require often an interruption or termination of CDT affecting clinical outcome of the patients. Recently we examined a new access site bleeding protection device during CDT.

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Revascularization Outcomes in Patients With Acute Limb Ischemia and Active Neoplastic Disease

Journal of Endovascular Therapy ◽

10.1177/1526602820954285 ◽

2020 ◽

pp. 152660282095428

Author(s):

Angeliki Argyriou ◽

Alexandros Kafetzakis ◽

Athanasios Saratzis ◽

Bella Huasen ◽

Raphaël Coscas ◽

...

Keyword(s):

Overall Survival ◽

Cox Regression ◽

Treatment Options ◽

Limb Ischemia ◽

Free Time ◽

Neoplastic Disease ◽

Acute Limb Ischemia ◽

Cox Regression Analysis ◽

Increased Risk ◽

Common Diagnosis

Purpose To report the outcomes of surgical (ST), endovascular (ET), and hybrid (HT) treatment in cancer patients with acute limb ischemia (ALI). Materials and Methods A multicenter retrospective registry collected 139 patients (mean age 72.3±12.4 years; 73 men) with ALI and active malignancy treated by ET (41, 29%), ST (70, 51%), or HT (28, 20%) in 7 European centers between July 2007 and February 2019. In 22 cases (16%) ALI was the first manifestation of the malignancy. Lung cancer was the most common diagnosis (38, 27%). The primary composite outcome was amputation-free survival (AFS). Overall survival, amputation-free time (AFT), and reintervention-free time (RFT) were also assessed. Cox regression analysis was applied to identify independent risk factors for the primary and secondary outcomes. Results are presented as the hazard ratio (HR) and 95% confidence intervals (CIs). Results ET was associated with improved 12-month AFS compared with both ST (HR 2.27, 95% CI 1.20 to 4.28, p=0.002) and HT (HR 2.14, 95% CI 1.09 to 4.18, p=0.008). ST (HR 2.50, 95% CI 1.19 to 5.53, p=0.003) and HT (HR 3.10, 95% CI 1.45 to 6.65, p<0.001) were related to an increased risk for mortality compared with ET. At 12 months, the AFT was similar between the 3 groups (ET vs ST: HR 1.52, 95% CI 0.51 to 4.53, p=0.45 and ET vs HT: HR 1.21, 95% CI 0.36 to 4.11, p=0.73). The 12-month RFT also did not differ significantly between the 3 treatment options (ET vs ST: HR 1.10, 95% CI 0.49 to 2.46, p=0.79 and ET vs HT: HR 0.51, 95% CI 0.22 to 1.17, p=0.19). ST and/or HT increased the risk for the major amputation and/or death (HR 1.76, 95% CI 1.05 to 2.05, p=0.03), while Rutherford class I ischemia (HR 0.12, 95% CI 0.02 to 0.90, p=0.04) and previous vascular interventions on the index limb (HR 0.55, 95% CI 0.32 to 0.97, p=0.04) showed a protective effect. Conclusion In patients with ALI and active malignant disease, ET was associated with increased AFS and overall survival compared with both ST and HT, while the limb salvage and reintervention rates were comparable among the 3 groups.

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Endovascular treatment of intra-aortic balloon pump-induced acute limb ischemia

Catheterization and Cardiovascular Interventions ◽

10.1002/ccd.21177 ◽

2007 ◽

Vol 70 (1) ◽

pp. 140-144 ◽

Cited By ~ 1

Author(s):

Andrew J. Klein ◽

John C. Messenger ◽

Ivan P. Casserly

Keyword(s):

Endovascular Treatment ◽

Limb Ischemia ◽

Acute Limb Ischemia ◽

Intra Aortic Balloon Pump

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Endovascular Procedures For Lower Extremity Vascular Disease: Specifics of Endovascular Treatment

10.2310/vasc.2388 ◽

2018 ◽

Author(s):

Lalithapriya Jayakumar ◽

Mark Davies

Keyword(s):

Lower Extremity ◽

Endovascular Treatment ◽

Vascular Disease ◽

Endovascular Procedures ◽

Limb Ischemia ◽

Arterial Disease ◽

Surgical Approaches ◽

Acute Ischemia ◽

Acute Limb Ischemia ◽

Chronic Ischemia

The application of endovascular procedures to lower-extremity vascular disease is well established for many common vascular diseases and has often supplanted conventional open surgical approaches. Endovascular therapy for arterial disease in the lower extremity encompasses treatment of acute ischemia, chronic ischemia, and aneurysmal disease. The fundamental skill set and techniques employed are common to all these processes. This chapter details the management of chronic ischemia, acute lower-extremity arterial ischemia, pseudoaneurysms and aneurysms, and arteriovenous malformations. Key words: access closure, access complications, acute limb ischemia, aneurysm endovascular treatment, chronic limb ischemia, intravascular ultrasonography, lower-extremity angiogram, lower limb ischemia, percutaneous transluminal angioplasty, transcollateral access, transpopliteal access

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