Simple technique of distal leg perfusion during heart transplant in patients with preoperative veno-arterial extracorporeal membrane oxygenation support

Direct heart transplant from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support is challenging. Continuation of postoperative VA-ECMO support may be required in the setting of primary graft dysfunction or severe vasoplegia. We describe a simple technique to perfuse the ipsilateral leg of an arterial ECMO cannula during heart transplant while the ECMO circuit is turned off but maintaining the arterial cannula and distal perfusion catheter in place. This technique minimizes the number of intraoperative procedures with a minimal risk of leg ischemia, and provides a smooth transition to postoperative VA-ECMO support if necessary.

Is Surgical Thrombo-Embolectomy in Acute Limb Ischemia Still Advantageous in Patients More Than 65 Years of Age?

Objective: In this study, we investigated the benefits of using Fogarty balloon catheterization in the treatment of acute leg ischemia with respect to amputation, fasciotomy, and mortality in older patients. Methods: A total of 102 patients age >65 who had a Fogarty thrombo-embolectomy for acute thromboembolic limb ischemia were investigated retrospectively. Patients were evaluated based on Rutherford IIa and IIb criteria and duration of ischemia. Duration of ischemia was divided into 3 categories (as 0 to 4, 4 to 8, and >8 hours) to evaluate the effect of ischemia period on vital parameters and mortality. Analysis with Cox regression showed that 30-day mortality was associated with older age and number of comorbidities such as amputation and fasciotomy. Results: In 102 patients >65 years of age who underwent embolectomy, rates were 7.2% fasciotomy (n = 7) and 13.7% amputation (n = 14), and 10 patients died (9.8%). According to multiple regression analysis, the surgical risk increases 1074 times when each year is added to the chronological age of over 65 years. Conclusion: In a majority of cases, limb salvage can be obtained via simple embolectomy rather than risking intravenous iodinated contrast. Although alternatives in older patients are limited, the Fogarty catheter should be regarded as a first-line treatment because of its ease of use and low complication rate.

Tips and Tricks in Below-Knee Peripheral Artery Disease Interventions

Critical leg ischemia, which threatens lower extremity and life, is an important form of lower extremity peripheral artery disease. Below-knee peripheral artery disease is an important part of critical leg ischemia. The most important treatment of below-knee peripheral artery disease is endovascular treatment. Knowing the endovascular treatment techniques is very important in increasing the success of the procedure. For this reason, we have presented this mini review called tips and tricks in below-knee peripheral artery disease interventios.

Regional oxygen saturation change rate for detection of leg ischemia in minimally invasive cardiac surgery

Introduction: The criteria for placement of distal perfusion cannulas vary among reports. This cohort study aimed to establish a reproducible method to monitor critical leg ischemia during minimally invasive cardiac surgery. Methods: We included 121 patients who underwent minimally invasive cardiac surgery via right thoracotomy with right femoral arterial cannulation from 2015 to 2018. The change rate of regional oxygen saturation (ΔrSO2) was calculated as follows: rSO2 (baseline) − rSO2 (actual number)/rSO2 (baseline). Patients were divided into Group N (ΔrSO2 < 40%): 100/121 (83%) and Group H (ΔrSO2 > 40%, <10 minutes if >40%): 21/121 (17%). A distal perfusion cannula was placed when ΔrSO2 was >40% over 10 minutes. Results: No patients experienced significant leg ischemia. Significantly longer cardiopulmonary bypass and aortic cross-clamp times were observed in Group H than in Group N (cardiopulmonary bypass time, 129 ± 36 minutes (Group N) vs. 151 ± 34 minutes (Group H), p = 0.01). ΔrSO2 correlated positively with plasma creatine phosphokinase elevation (R = 0.40, p < 0.001) on postoperative day 1. Serum lactate on intensive care unit admission showed a significant positive correlation (R = 0.40, p < 0.001) with ΔrSO2. Conclusion: ΔrSO2 measurement by near-infrared spectroscopy can facilitate distal leg perfusion monitoring and assist surgeons in preventing critical leg ischemia during minimally invasive cardiac surgery.

Symptomatic Aortic Endograft Occlusion in a 70-year-old Male

Case Presentation: A 70-year-old male with prior aorta endovascular aneurysm repair presented with progressive lower extremity weakness over the course of several hours. There was noted loss of palpable bilateral femoral pulses in the emergency department. Computed tomography angiography revealed a kinked and occluded aortic endograft. He subsequently underwent successful axillobifemoral bypass revascularization. Discussion: Kinking of endograft limbs and occlusion has been reported in a small percentage of patients. Bilateral leg ischemia due to aortic endograft occlusion is rare.

Peripheral leg ischemia detected via intraoperative neurophysiological monitoring during a multilevel complex anterior and posterior operation

Intraoperative neurophysiologic monitoring is a technique utilized during spinal operations to minimize sensory and motor function morbidity. We herein report a case of a 73-year-old female with renal cell carcinoma and metastatic involvement of the cervical and thoracic spine, who underwent a multilevel complex anterior and posterior operation. Neurophysiological monitoring was able to localize the lower limb ischemia utilizing somatosensory evoked potentials. This prompted intraoperative investigation of the peripheral ischemia, and the patient was found to have an Angio-Seal device embolus in the right popliteal artery that dislodged from the right femoral artery.