First Experience With The GoBack-Catheter For Successful Crossing of Complex Chronic Total Occlusions in Lower Limb Arteries

Purpose: To evaluate the use of the GoBack-catheter (Upstream Peripheral Technologies) in complex revascularizations in lower limb arteries. Materials and Methods: In this retrospective single-center study, the results of the first 100 consecutive patients including 101 limb-revascularizations, performed between May 2018 and July 2020 with the study device, were analyzed. In all cases, guidewire-crossing failed, and all lesions were chronic total occlusions (CTO), either de novo, reocclusions, or in-stent reocclusions. Successful crossing was defined as passing the CTO using the study device. Patency at discharge and after 30 days was defined as less than 50% restenosis on duplex sonography, without target lesion revascularization. Results: Median lesion length was 24 cm and 38 patients (37.6%) had a calcium grading according to the peripheral arterial calcium scoring system (PACSS) of 4 or 5. In 20.8% of patients, an occluded stent was treated. CTOs involved the femoropopliteal segment in 91.1%, iliac arteries in 5.9%, and tibial arteries in 7.9%. The GoBack-catheter was employed for entering into or crossing through parts or the full length of a CTO or an occluded stent as well as for re-entering into the true lumen after subintimal crossing. The device was used via contralateral and ipsilateral antegrade as well as retrograde access with an overall technical success rate of 92.1%. In 3 patients minor bleeding occurred at the crossing or re-entry site, which were managed conservatively. Thirty-day adverse limb events comprised minor amputations in 4 patients (4.0%), 1 major amputation (1.0%), and reocclusions in 7 limbs (6.9%). Conclusion: The new GoBack-catheter offers versatile endovascular applicability for complex CTO recanalization in a broad range of peripheral vascular interventions with a high technical success and low complication rate.

FORMATION OF OUTFLOW PATHWAYS IN PATIENTS WITH COMBINED STENOTIC-OCCLUSIVE LESIONS OF THE FEMORAL AND TIBIAL ARTERIAL SEGMENTS

The aim of the study. To prevent the development of postoperative thrombosis of the reconstruction segment after endovascular and hybrid revascularization of the femoral-distal arterial portion in the conditions of stenotic-occlusive process of the tibial arteries by forming functionally capable pathways in the tibial segment. Materials and methods. The results of treatment 135 patients with atherosclerotic occlusive-stenotic lesions of the infrainguinal arterial segment of the lower extremities were analyzed. According to the severity violation of chronic arterial insufficiency of the lower extremities, grade IIB was detected in 50 (37.04%) patients, grade III - in 63 (46.66%) examinee, grade IV- in 22 (16.30%) examinee. Patients were divided into 2 groups. Group I included 61 (45.19%) patients with occlusal-stenotic lesions at the level of the infrainguinal segment, who underwent only endovascular correction of the peripheral arterial portion, the second group consisted of 74 (54.81%) patients with multilevel occlusive-stenotic lesions of the infrainguinal arterial segment which was performed hybrid arterial reconstruction. Results and discussion. The proposed tactic involves endovascular angioplasty of at least two tibial arteries. During revascularization of 135 patients by endovascular (61 supervision) and hybrid (74 supervision) methods of a femoral-distal arterial blood flow under conditions of arterial sclerotic disease of tibial arteries carried out in 115 (85,18%) patients endovascular dilatation of two arteries. Thrombosis of the reconstruction segment in the postoperative period was finding in 9 (6.67%) cases: when using endovascular and hybrid revascularization methods, respectively - in 4 (6.56%) and 5 (6.76%) cases. Thrombosis of the reconstruction segment in the early postoperative period in 8 cases developed after endovascular angioplasty of one of the tibial arteries and only in 1 observation after endovascular angioplasty of 2 tibial arteries. Conclusion. Reconstruction of outflow pathways at the tibial arterial segment with occlusive-stenotic lesions of the infranguinal arterial portion during endovascular and hybrid techniques of revascularization by performing angioplasty of the two tibial arteries of the tibia can provide a positive result of revascularization in the early postoperative period, respectively in 95.08% and 95.95% of cases.

Case Report: An Unusual Case of Acute Lower Limb Ischemia as Precursor of the Asherson's Syndrome

Introduction: Asherson's Syndrome, also defined as Catastrophic Antiphospholipid Syndrome (CAPS), represents the most severe manifestation of Antiphospholipid Antibody Syndrome. Rarely, the first CAPS diagnosis is based on macro-thrombotic event as acute limb ischemia.Case Presentation: We present a case of a 65-year-old woman admitted with an acute lower limb arterial ischemia with a complete occlusion of all the three tibial vessels. Three endovascular recanalization procedures were performed contemporary to 48 h intraarterial thrombolysis administration. The patency of tibial arteries was restored with a near-complete absence of digital arteries and microvessel perfusion of the foot. In the following days, an aggressive foot gangrene was established, leading to a major lower-limb amputation. Due to the general clinical status worsening and aggressiveness of ischemic condition, further investigations were performed leading to the diagnosis of an aggressive Asherson's Syndrome that was also complicated by a severe heparin-induced thrombocytopenia. Medical management with a high dose of intravenous steroids and nine sessions of plasma exchange led to a clinical condition stabilization.Conclusion: In our case, the presence of a “sine causa” acute arterial occlusion of a large vessel represented the first manifestation of an aggressive form of Asherson's Syndrome that could represent a fatal disease. Due to the extreme variety of manifestations, early clinical suspicion, diagnosis, and multidisciplinary management are essential to limit the life-threatening consequences of patients.

Thrombosis of the right iliac, femoral, popliteal, and tibial arteries in a post-COVID-19 in adolescent

Background Viral infection into lung, muscular, and endothelial cells results in inflammatory response, including edema, degeneration, and necrotic alterations. The involvement of the major arteries in adolescent with COVID-19 has been infrequently reported in the literature. The aim of the present study is to report thrombosis of the right iliac, femoral and tibial arteries and stenosis of left iliac artery in an adolescent with COVID-19 and to discuss the pathophysiological hypotheses. Case presentation We report the case of a 17-year-old female patient with COVID-19 infection. She was seen at the physician specialized general medicine in her hometown, was diagnosed with COVID-19 but did not require hospitalization. After 15 days, she had sudden pain in the left leg that has limited her ability to walk more than 10 met, associated with extremity cyanosis and coldness. Angiotomography revealed thrombosis of a portion of the iliac and popliteal arteries. Na emergency embolectomy was successfully performed, followed by full-dose heparinization with unfractionated heparin. Conclusion Arterial thrombosis of large arteries may be associated with chronic inflammatory syndrome secondary to COVID-19 infection and the treatment with a late embolectomy was successful, even in a thrombotic event.

Retrograde Revascularization of Tibial Arteries in Patients with Critical Limb Ischemia: Plantar-Arch Versus Transpedal Approach

Purpose: To compare retrograde plantar-arch and transpedal-access approach for revascularization of below-the-knee (BTK) arteries in patients with critical limb ischemia (CLI) after a failed antegrade approach. Materials and Methods: Retrospectively we identified 811 patients who underwent BTK revascularization between 1/2014 and 1/2020. In 115/811 patients (14.2%), antegrade revascularization of at least 1 tibial artery had failed. In 67/115 (58.3%), patients retrograde access to the target vessel was achieved via the femoral access and the plantar-arch (PLANTAR-group); and in 48/115 patients (41.7%) retrograde revascularization was performed by an additional retrograde puncture (TRANSPEDAL-group). Comorbidities, presence of calcification at pedal-plantar-loop/transpedal-access-site, and tibial-target-lesion was recorded. Endpoints were technical success (PLANTAR-group: crossing the plantar-arch; TRANSPEDAL-group: intravascular placement of the pedal access sheath), procedural success [residual stenosis <30% after plain old balloon angioplasty (POBA)], and procedural complications limb salvage and survival. Correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were tested. Results: Technical success was achieved in 50/67 (75%) patients of the PLANTAR-group and in 39/48 (81%) patients of the TRANSPEDAL-group (p=0.1). Procedural success was obtained in 23/67 (34%) patients of the PLANTAR-group and in 25/48 (52%) patients of the TRANSPEDAL-group (p=0.04). In 14/49 (29%) cases with calcification at the pedal–plantar loop, technical success was not achieved (p=0.04), and in 33/44 (75%) patients with calcification at the tibial-target-lesion, procedural success was not attained (PLANTAR-group) (p=0.026). In the TRANSPEDAL-group, correlations between calcification at access site/tibial-target-lesion and technical/procedural-success were not observed (p=0.2/p=0.4). In the PLANTAR-group, minor complications occurred in 13/67 (19%) and in the TRANSPEDAL-group in 4/48 patients (8%) (p=0.08). Limb salvage at 12 (18) months was 90% (82%) (PLANTAR-group; 95%CI 15.771–18.061) and 84% (76%) (TRANSPEDAL-group; 95%CI 14.475–17.823) (Log-rank p=0.46). Survival at 12 (18) months was 94% (86%) (PLANTAR-group; 95%CI 16.642–18.337) and 85% (77%) (TRANSPEDAL; 95%CI 14.296–17.621) (Log-rank p=0.098). Conclusion: Procedural success was significantly higher using the transpedal-access approach. Calcifications at pedal–plantar loop and target-lesion significantly influenced technical/procedural failure using the plantar-arch approach. No significant difference between both retrograde techniques in terms of feasibility, safety, and limb salvage/survival was found.

Cardiovascular Pathology – a Factor of the Adverse Course of Diabetic Polyneuropathy

Diabetic polyneuropathy (DP) and angiopathy are interdependent processes, as disturbances in the microcirculatory system of peripheral nerves lead to increased axonal damage and is a kind of predictor of polyneuropathy progressing [6]. 80% of deaths from diabetes mellitus (DM) are associated with cardiovascular catastrophes, including coronary heart disease (CHD), stroke and peripheral artery disease [3]. The objective: to analyze the most common cardiovascular pathology (CVP) and show its impact on the course of DP in type I and II DM. Materials and methods. Was clinically examined 101 patient with DP. The examined patients were divided into groups: with DP on the background of type 1 DM (group I) (n=54) and with DP on the background of type II DM (group II) (n=47), and also were divided into subgroups: DP on the background of type I and II DM and existing CVP (including diabetic angiopathy) 82 (82%) (subgroup А) and with the DP on the background of DM type I and II without CVP – 19 (19%) (subgroup В). Patients were examined to determine the neurological status, were performed laboratory and instrumental methods of examination. Static calculation was performed in MS Excel 2003 and in the programme STATISTICA 10. Results. Regarding to the patients of subgroup А and В we noted the natural predominance of trophic disorders, changes in the reflex sphere and sensitivity in subgroup А. Patients of group II more often than in group I had pathology of the cardiovascular system. Hypertension (HT) and CHD in both cases were registered with a high frequency. In subgroup А there was a combination of several nosologies: from the respiratory, urinary, gastroenterological system (1%), urinary and gastroenterological (3%), gastroenterological and endocrine (2%), urinary and endocrine (1%). In subgroup В diseases of urinary and gastroenterological pathology were found in (5%), gastroenterological (5%), endocrine (11%). The examined patients from group I and with the concomitant CVP have lower linear velocity of blood flow (LVBF) on both tibial arteries, patients in group II – have marginally higher LVBF. Analysis of the results of duplex scanning of lower extremity arteries showed a high incidence of stenosis, in particular the anterior tibial arteries (ATA) up to 30–40%, posterior tibial arteries (PTA) up to 40–50% and occlusion (PTA and femoral, popliteal, tibial segment) in individuals of group I. Conclusions. In patients with DP on the background of type I and II DM and available CVP (subgroup А), the clinical manifestations of polyneuropathy were quite pronounced, especially in the field of trophic disorders, because CVP enhances the ischemia of the microsaceous channel of the peripheral nerves. In addition, persons with concomitant CVP have a wide range of another comorbid pathology, which accelerates the onset of DM complications.

Late results of surgical treatment of critical ischemia of the lower extremities after one-staged direct revascularization

Objective. To optimize the tactics of surgical treatment in patients, suffering chronic ischemia of the lower extremities with the help of elaboration and introduction of a one-staged direct and indirect revascularization into clinical practice. Materials and methods. Analysis of the treatment results in 162 patients, suffering obliterating atherosclerosis of the lower extremities vessels, who were treated in stationary in Department of Vascular Surgery of Zakarpattya Regional Clinical Hospital named after Andriy Novak in 2015 - 2020 yrs. The patients were distributed in accordance to the lower extremities ischemia degree: ІІB – 7 (4.3%), ІІІA – 61 (37.7%), ІІІB – 58 (35.8%), ІV – 36 (22.2%). All the patients have had atherosclerotic affection of femoro-ankle-foot segment of the main arteries with preservation of central blood flow in aorto-iliac segment. Results. Occlusion of femoral artery was noted in all patients. Occlusion of anterior tibial artery was revealed most frequently – in 72% of the patients, than in fibular - in 42% of patients (p=0.00), and equally frequently with occlusion of posterior tibial artery – in 68% (p=0.61). The foot arteries were involved into the process in 51 (31.5%) patients. Affection of 2-3 arteries of the shin were registered more frequently, than occlusion of one artery – in 109 (67.3%) and 48 (26.5%) patients, accordingly. Occlusive-stenotic affection of popliteal artery have had 127 (78.4%) patients. Mostly frequent affection of the shin arteries was observed in basin of anterior tibial artery – in 67 (41.4%) patients, as well as in combined affection of anterior and posterior tibial arteries - in 45 (27.8%) patients. Іsolated affection of posterior artery was revealed in 36 (22.2%) patients. Combined affection of posterior tibial and fibular was observed in 14 (8.6%) patients. Conclusion. Efficacy of indirect revascularization after the arterial inflow restoration is more prognosticated, than efficacy of its isolated conduction in environment of chronic critical ischemia of the lower extremities. Combined application of direct and indirect revascularization guarantees more secure positive result in remote postoperative period and enhancement of the extremities preservation index.

COVID-19-Related Spontaneous Aortic Arch Thrombus With Delayed Embolization

Presentation of a 62-year-old man with baseline chronic obstructive pulmonary disease admitted to the hospital with dyspnea and newly diagnosed COVID-19 infection. CT scan of the chest was obtained to rule out pulmonary embolism. This revealed a mural thrombus of the inner curvature of the aortic arch with a floating component. Therapeutic full dose anticoagulation was initiated in combination with close clinical observation and treatment for modest hypoxia. He did well for 1 month and then returned with ischemic rest pain of the right foot. Angiography revealed thrombosis of all 3 tibial arteries in the right leg. Percutaneous mechanical thrombectomy with tissue plasminogen activator injection and angioplasty was performed with success in 1 tibial artery to achieve in line flow to the foot. After continued anticoagulation, the remainder of the tibial arteries autolysed and the aortic thrombus was noted to be resolved 4 months later. A brief pathophysiology discussion is included.