Safety and Efficacy of Hybrid Angiography in Chronic Lower Extremity Ischemia Patients at Risk of Contrast-Induced Acute Kidney Injury

Aim The aim of the study was to assess the feasibility and safety of hybrid angiography consisting of carbon dioxide (CO2) angiography supplemented by small doses of iodinated contrast medium (ICM) in the endovascular treatment of chronic limb threatening ischemia (CLTI) patients with pre-existing chronic kidney disease (CKD). Patients and Methods This prospective study comprised all non–dialysis-dependent CKD patients presenting for endovascular management of CLTI. All endovascular interventions were done using CO2 as a contrast medium whether alone or supplemented by ICM (hybrid angiography) to treat unilateral arterial steno-occlusive lesions of iliac, femoropopliteal, or BTK arteries. Study outcomes included feasibility of the device, technical success, and freedom from contrast-induced acute kidney injury (CI-AKI), renal replacement therapy, and CO2 angiography-related complications. Results A total of 206 CKD patients underwent endovascular intervention using CO2 only as a contrast medium (159 patients, 77.2%), or hybrid CO2-ICM angiography (47 patients, 22.8%). The overall technical success was 95.6%. Patients were followed up for a mean period of 17.9 ± 4.6 months. The mean volumes of CO2, and ICM consumption were 200.7 ± 95.1 mL, and 11.8 ± 4.4 mL, respectively. The mean procedural, and fluoroscopy times were 95.6 ± 12.5 and 49.5 ± 10.8 minutes, respectively. BTK lesions were significantly associated with the need for hybrid angiography ( P = <.0001). The mean pre- and postoperative serum creatinine levels were comparable ( P = .08). Two patients (4.3%) showed transient manifestations of CI-AKI, but neither required renal replacement therapy. No statistically significant differences were encountered between the two study groups regarding procedure outcomes. Conclusion Hybrid CO2-ICM angiography is safe, feasible, effective, and a fairly simple alternative during endovascular interventions to treat chronic lower extremity ischemia. Using supplemental small volumes of ICM to overcome the suboptimal images generated by CO2 alone does not jeopardize the renal functions in CKD patients.

Clinical Analysis of Risk Factors for Mortality in Type A Acute Aortic Dissection: A Single Study From China

Objective: Acute type A aortic dissection (ATAAD) is a fatal condition that requires emergency surgery. The aim of the present study was to determine pre- and intra-operative risk factors for in-hospital mortality in patients with ATAAD.Methods: Consecutive 313 patients with ATAAD who underwent emergency surgery at our hospital from February 2012 to February 2017 were enrolled in our study. Univariate and multivariate logistic regression analysis were performed to identify the pre-operative and intra-operative risk factors for in-hospital mortality.Results: Of the 313 patients, 32 patients (10.2%) died. Compared with survivors, non-survivors had higher heart rate, serum potassium level and EuroSCORE II, and higher incidence of moderate to severe pericardial effusion, supra-aortic vessels involvement, myocardial ischemia and lower-extremity ischemia. As for surgery-related factors, the duration of surgery and cardiopulmonary bypass time were longer in non-survivors than survivors. In addition, non-survivors were more likely to undergo coronary-artery bypass graft compared with survivors. On multivariate analysis, elevated plasma potassium level (OR: 43.0, 95% CI: 3.8–51.5, p &lt; 0.001), high incidence of supra-aortic vessels involvement (OR: 4.4, 95% CI: 1.5–7.0, p = 0.008) and lower-extremity ischemia (OR: 4.9, 95% CI: 1.6–6.9; p = 0.009), and longer duration of surgery (OR 6.0, 95% CI: 1.8–18.7, p = 0.000) and cardiopulmonary bypass time (OR: 3.7, 95% CI: 1.3–9.3, p = 0.001) were independently predictive of higher mortality in patients with ATAAD.Conclusions: Supra-aortic vessels involvement, lower-extremity ischemia and elevated plasma potassium level are independent predictors of mortality in patients with ATAAD. A significant decrease in duration of surgery and cardiopulmonary bypass time is helpful to improve survival of patients.

Auto-venous femoral-popliteal bypass in patients with critical lower extremity ischemia and coronary heart disease associated with diabetes melitus

Аim — to improve the results of treatment of patients with atherosclerotic lesions of the arteries of femoral-popliteal segment, who underwent auto­venous femoral-popliteal bypassgrafting.Materials and methods. During the period of years 2018 to 2021, 34 patients with critical ischemia of the lower extremities underwent autovenous shunting with a reversed great saphenous vein with treatment of the inner surface of the vein with a solution of cytostatics (paclitaxel). Besides, the treatment was analysed in two control groups, who underwent autovenous reverse vein shunting (30 patients) and autovenous in-situ shunting (33 patients). The follow-up periods lasted for 24 months. The evaluation criteria included the cases of shunt thrombosis, shunt stenosis, mortality, serious ischemic events — acute lower extremity ischemia, myocardial infarction, ischemic stroke, cases of high amputations of the lower extremities.Results. In the postoperative period, no deaths were observed; absence of complicationswas registered in 96 (98 %) patients. In the main group, the frequency of shunt thrombosis was 5 (14.7 %), hemodynamically significant restenosis was diagnosed in 6 patients (17.6 %), acute myocardial infarction in 1 patient (2.9 %). In the comparison group, 11 cases of autovenous shunt thrombosis were defined.Conclusions. Our clinical experience showed promising short- and medium-term results. The chosen surgical approach and topical application of cytostatic drugs enabled to achieve long-term patency of venous shunt, which is of particular importance for patients with diabetes mellitus.

Treatment of patients with occlusive-stenotic diseases of the arteries by endovascular method

Annotation. The case of successful treatment of a patient with critical lower extremity ischemia illuminates the possibilities of different approaches of the endovascular surgical method. The results of treatment of patients with occlusive-stenotic diseases of the lower extremities arteries as a result of obliterating atherosclerosis were analyzed. 243 patients underwent endovascular surgery. 14 (5.76%) patients were previously operated on. The multi-storey lesions were found in 35 (14.4%) cases. Most patients were ranged in age from 46 to 86 years. There were 175 men (72.0%) and 68 women (28.0%). The right lower extremity was affected more often – 148 (60.9%) patients than the left ones – 95 (39.1%). The thrombosis was diagnosed in 21 (10.6%) individuals as the most common complications in the early postoperative period. Limb amputation was performed in 12 patients. Mortality rate in the early postoperative period was 2.56% (4 patients died). It is established that the methods of choice in the reconstruction of stenotic-occlusive lesions of the arteries are: balloon angioplasty (and stenting), rotor-mechanical thromboaspiration, regional thrombolytic therapy. These methods are performed mainly under local anesthesia, they are minimally invasive and can be used in patients with severe comorbidities.

Clinical Analysis of risk factors for 30-day mortality in type A acute aortic dissection: a single-center study from China

Objective: This study was conducted to evaluate pre- and intraoperative risk factors for 30-day mortality in patients with acute type A aortic dissection (ATAAD). Methods: Three hundred thirteen patients with ATAAD who underwent emergency surgery (264 men and 49 women; mean age, 48±10 years) were enrolled in our study. Preoperative and operative risk factors for death were presented. Multivariable analysis was performed to identify the influence of varying factors on 30-day mortality. Results: Overall, 32 patients (10.2%) died within 30 days. Compared with the surviving group, the deceased patients were more likely to have tachycardia, elevated serum potassium levels, moderate to severe pericardial effusion, suprasternal branch involvement, myocardial ischemia, and lower-extremity ischemia. Regarding factors related to surgery, the duration of surgery and cardiopulmonary bypass and concomitant procedures of coronary artery bypass graft（CABG） were greater in patients who died. In multivariate analysis, independent risk factors were longer duration of surgery (odds ratio [OR]: 4.5, p=0.001) and cardiopulmonary bypass (OR: 5.3, p=0.001), moderate to severe pericardial effusion (OR: 3.3, p=0.017), suprasternal branch involvement (OR: 4.9，p=0.002), and lower-extremity ischemia (OR: 7.6, p＜0.001). Conclusions: Lower-extremity ischemia and suprasternal branch involvement have the poorest outcomes. Moderate to severe pericardial effusion could influence the outcome. Shorter duration of surgery is associated with better outcomes. Key Words: acute type A aortic dissection, surgery, mortality, risk factors