Angioscopic Findings of Stenosis Versus Occlusion in Femoropopliteal Artery Disease.

BACKGROUND: Despite the increase in the number of patients with peripheral artery disease (PAD), the pathophysiology is not fully elucidated. Recently, angioscopy with a 0.48-megapixel equivalent resolution camera became available for patients with PAD. We aimed to compare the plaque component between native stenosis and occlusion in the femoropopliteal artery using this modality. MATERIALS AND METHODS: Thirty-two consecutive patients who underwent endovascular treatment for native femoropopliteal artery disease with angioscopy were studied. The major angioscopic classifications of each lesion were defined as follows: atheromatous plaque (AP) was defined as luminal narrowing without any protrusion, calcified nodule (CN) was defined as a protruding bump with surface irregularity, a mainly reddish thrombus was defined as organizing thrombus (OG), and organized thrombus (OD) was defined by more than half of the thrombus showing a whitish intima-like appearance. RESULTS: A total of 34 lesions (stenosis, n=18; occlusion, n=16) from 32 patients were included. All stenotic lesions showed AP or CN (n=8 [44%], n=10 [56%], respectively), whereas all occluded lesions showed OG or OD (n=5 [31%], n=11 [69%], respectively), which amounted to a statistically significant difference (p<0.001). In occluded lesions, stiff wires (>3 g) were required to cross all lesions classified as OD, whereas this was not always necessary for lesions classified as OG (11 [100%] of 11, 1 [25%] of 5, respectively; p=0.04). Yellow color plaques were observed to a similar degree in all angioscopic classifications. Major adverse limb events, defined as amputation and any reintervention at 12 months, were highly variable, depending on the angioscopic findings, and tended to be more frequently observed in CN and OD (13% in AP, 40% in CN, 0% in OT, and 36% in OD, p=0.25). CONCLUSION: Angioscopy revealed varying components in stenosis and occlusion with different degrees of clinical impact. This may provide new information on the pathophysiology of PAD.

A Large Vascular Leiomyoma Arising from the Superficial Femoral Artery: Case Report and Systematic Review.

OBJECTIVE: Vascular leiomyomas are rare begin tumor comprising mature vascular smooth muscles that originate in the tunica media of the blood vessels. Most of the tumors arise from the veins. Only a dozen cases of artery-arising vascular leiomyoma have been reported, most of which are presented as small nodules in the hand. METHODS: Here we report an interesting case of a large artery-arising vascular leiomyoma and perform a systematic review. RESULTS: A 55-year-old man complained a 6 × 3 cm firm, mobile, tender and pulseless mass in the medial region of his left thigh. The computed tomography showed a well-demarcated fusiform tumor encircling the superficial femoral artery and was enhanced significantly with contrast. The patency of the superficial femoral artery was intact. The magnetic resonance image exhibited slightly hypointense relative to skeletal muscle on T1-weighted images and a heterogeneous appearance on T2-weighted images. We performed the en bloc resection of the tumor and used a vascular graft to revascularize the artery through end-to-end anastomosis. After histopathological assessments, the tumor was diagnosed as an artery-arising vascular leiomyoma. We also performed a systematic review on artery-arising leiomyomas, discovering 21 cases. Most of the artery-arising vascular leiomyomas were small nodules (mean length: 2.4cm) and most of them were superficial solitary mass located in the hand (13 cases, 62%). Excision of the tumor was an effective treatment. The histological subtype of the artery-arising vascular leiomyoma in all cases was solid type. During the follow-up of each patient, there was no recurrence. CONCLUSIONS: Artery-arising vascular leiomyomas are extremely rare. Most of them are painless and locate in the hand. Their pathological subtype is solid type in all patients. Due to their begin nature, excision is a cure with little chance of recurrence.

[Hybrid intervention for an atherosclerotic lesion of arteries of the iliofemoral segment]. / Gibridnoe vmeshatel'stvo pri ateroskleroticheskom porazhenii arterii podvzdoshno-bedrennogo segmenta.

The article describes a clinical case report regarding a successfully performed hybrid intervention in a patient presenting with critical ischaemia of a lower limb and an atherosclerotic lesion of arteries of the iliofemoral segment. Endovascular reconstruction in an isolated manner turned out to be impossible for both technical and anatomical reasons, whereas open reconstruction required two surgical accesses, an extended scope of the operation, and the use of a synthetic graft. Using a hybrid approach favourably contributed to adequate restoration of blood flow in the ischaemized limb, a decrease in the traumatic nature of the intervention, and also ensured angiographic control over the state of the operated arterial segment.

[PROCURING OF ІNTRAOPERATIVE HEMOSTASIS IN REVASCULARIZATION INTERVENTIONS].

Results of the hemostasis conduction in conditions of revascularization in 106 patients, оperated on for atherosclerotic affection of aorta and the main arteries of the lower extremities, were adduced. Syndrome of hypercoagulation of traumatic stage of surgical intervention in early postoperative period is developing due to thrombinemia on background of a fibrinolytic system depression. There was proved a necessity to impact on thrombin-fibrinous factor (factor ІІа) of hemocoagulant cascade by application of nonfractionized heparins immediately after conclusion of operative intervention with thromboprophylaxis prolongation, using low-molecular heparins (impact on Ха factor) in accordance to the branch standards.

A Rapid and Reliable End-To-End Anastomosis Technique for Emergency Vascular Surgery--A Case Report.

A 28 year old male presented to us with 8 hours old open fracture of distal shaft of left femur which was already stabilized with external fixator but had no palpable distal pulse both clinically and on doppler examination. He underwent a primary repair following limited segmental resection. Commonly end-to-end anastomosis techniques following transection of arteries include interrupted and continuous suturing with or without 'parachuting' of the vessel or graft. Here we offer a rapid and reliable technique with following advantages: i) operating system always towards the surgeon, ii) posterior row of suture placed as both ends are well visualized, iii) less chance of catching posterior wall, iv) flushing performed easily before completing anterior row suture. Upto 2nd post operative day anticoagulant used in the form of inj. Heparin 2500 IU subcutaneously 8 hourly and patient was discharged from hospital on 3rd post operative day with presence of good distal pulses both on clinical and Doppler examination. Fourteen days later, on follow up Duplex study showed normal arterial flow without any stenosis or occlusion.

Neuromuscular complications of the lower extremity after thrombectomy in a patient with superficial femoral artery occlusion: Case series.

BACKGROUND: Ischemia reperfusion (IR) injury may result in rhabdomyolysis and compartment syndrome when blood supply returns after thrombectomy for patients with acute limb ischemia. OBJECTIVE: We highlight the value of early diagnosis and treatment in post-thrombectomy patients with IR injuries in their lower legs. CASE DESCRIPTION: Two patients received thrombectomy due to left superficial femoral artery occlusion. Both patients complained of left calf pain during ambulation at the 1- and 3-day follow up post-thrombectomy, as well as a heating sensation, swelling, weakness, and sensory changes in the affected leg. For early diagnosis musculoskeletal ultrasounds were performed and in both cases revealed swelling and change of echogenicity in the left calf. To further diagnosis, magnetic resonance imaging of the left leg revealed limb IR-induced muscular injury and rhabdomyolysis, respectively. In both cases, an electrodiagnostic study revealed peripheral nerve injury in the left leg. Medications were provided for neuropathic pain control and early rehabilitation was performed to improve function. In both cases, patients reported during their follow-up that their pain and muscle weakness had improved. CONCLUSION: When post-thrombectomy calf pain occurs early evaluation and treatment should be performed to identify any potential IR injury.

Structural and Mechanical Properties of Human Superficial Femoral and Popliteal Arteries.

The femoropopliteal artery (FPA) is the main artery in the lower limb. It supplies blood to the leg muscles and undergoes complex deformations during limb flexion. Atherosclerotic disease of the FPA (peripheral arterial disease, PAD) is a major public health burden, and despite advances in surgical and interventional therapies, the clinical outcomes of PAD repairs continue to be suboptimal, particularly in challenging calcified lesions and biomechanically active locations. A better understanding of human FPA mechanical and structural characteristics in relation to age, risk factors, and the severity of vascular disease can help develop more effective and longer-lasting treatments through computational modeling and device optimization. This review aims to summarize recent research on the main biomechanical and structural properties of human superficial femoral and popliteal arteries that comprise the FPA and describe their anatomy, composition, and mechanical behavior under different conditions.

Longitudinal Magnetic Resonance Imaging-Based Superficial Femoral Artery Velocity Measurements in Diabetic and Nondiabetic Patients With Peripheral Artery Disease.

BACKGROUND: Longitudinal associations of noninvasive 2-dimensional phase-contrast magnetic resonance imaging (2D-PC-MRI) velocity markers of the superficial femoral artery (SFA) were analyzed along with the characteristics of peripheral artery disease (PAD). We hypothesized that the 2-year differences in MRI-based measures of SFA velocity were associated with longitudinal changes in markers of PAD. METHODS: A total of 33 (11 diabetic, 22 nondiabetic) patients with PAD with baseline and 2-year follow-up MRI scans were included in this secondary analysis of the Effect of Lipid Modification on Peripheral Artery Disease after Endovascular Intervention Trial (ELIMIT). Electrocardiographically gated 2D-PC-MRI was performed at a proximal and a distal location of the distal SFA territory. SFA lumen, wall, and total vessel volumes and the normalized wall index (NWI) were analyzed. RESULTS: Baseline characteristics did not differ between diabetic and nondiabetic PAD patients. Maximum proximal and distal SFA velocity measures did not differ between baseline and 2 years (41.98 interquartile range (IQR) (23.58-72.6) cm/s vs. 40.31 IQR (26.69-61.29) cm/s; P = 0.30). Pooled analysis (N = 33) showed that the 24-month change in the NWI was inversely associated with the 24-month change in the proximal maximal SFA velocity (beta = -168.36, R2 = 0.150, P value = 0.03). The 24-month change of the maximum velocity differences between the proximal and distal SFA locations was inversely associated with the 24-month changes in peak walking distance (beta = -0.003, R2 = 0.360, P value = 0.011). CONCLUSION: The 2-year change of SFA plaque burden is inversely associated with the 2-year change of proximal peak SFA blood flow velocity. 2D-PC-MRI measured SFA velocity may be of interest in assessing PAD longitudinally.

[Role of low-dose acetylsalicylic acid in comprehensive postoperative treatment of patients with lower-limb chronic arterial insufficiency].

The study comprised a total of 107 patients (all men) after endured femoropopliteal bypass grafting above the genicular fissure with a synthetic stent graft manufactured by the Gore Company for stage IIB and III chronic arterial insufficiency of the lower extremities according to the Fontain-Pokrovsky classification. Group One I (control group) was composed of fifty-four patients permanently taking in the postoperative period at the out-patient stage pentoxiphylline (trental 400 mg 1 tablet 3 times daily) and xantinol nicotinate at a dose of 150 mg one tablet thrice daily. Group Two (Study Group) consisted of fifty-three patients taking after reconstructive vascular surgery at the out-patient stage in addition to pentoxiphylline and xantinol nicotinate acetylsalicylic acid (cardiomagnil 75 mg 1 tablet once daily). The Control Group patients within 3 to 6 months of follow up were found to have a considerable progressing improvement of the functional abilities of the microcirculatory bed requiring in 44 (81.5%) cases hospitalization to the Surgical Department for intensive vascular therapy. Despite this fact four (7.4%) patients within the time frame from 6 to 9 months after surgery developed thrombosis of the vascular implant requiring a repeat surgical intervention. In the Study Group patients, the degree of functional capabilities of the microcirculatory bed in the postoperative period was less considerable, reaching the maximum after 10-12 months of follow up, with eighteen (34.0%) patients requiring hospitalization for additional vascular therapy to perform. There were no cases of implants' thrombosis in the Study Group patients. Pathological alterations in the functional state of the peripheral vascular bed correlated with viscosimetric indices and activity of blood platelet aggregation. The addition of antithrombocytic agents to conservative postoperative therapy considerably improved the outcomes of surgical treatment.

Subintimal Versus Intraluminal Approach for Femoropopliteal Chronic Total Occlusions Treated With Intravascular Ultrasound Guidance.

Background The subintimal approach (SA) is widely used in endovascular therapy for femoropopliteal chronic total occlusion lesions. However, when compared with the intraluminal approach (IA), the safety and efficacy of SA in real-world practice are not well characterized. Furthermore, there is a paucity of data on the clinical impact of subintimal and intraluminal wire passage (SWP and IWP, respectively) assessed by intravascular ultrasound. Methods and Results From the IVORY (Intravascular Ultrasound-Supported Endovascular Therapy in Superficial Femoral Artery) registry, this study included 500 patients undergoing endovascular therapy for femoropopliteal chronic total occlusion lesions (SA, n=67; IA, n=433; and SWP, n=186; IWP, n=314). The primary end point was the cumulative 1-year incidence of restenosis. The rate of perioperative complications was also assessed. Propensity score matching analysis was performed to adjust for the intergroup differences. After propensity score matching, the final study population consisted of 59 pairs (SA, n=59; IA, n=348) and 170 pairs (SWP, n=170; IWP, n=293), respectively. Cumulative 1-year incidence of restenosis was comparable between the SA and IA groups (41.0% versus 43.4%, P=0.40). No significant difference in 1-year restenosis rate between the SWP and IWP groups was observed (48.2% versus 40.8%, P=0.40), although the SWP group tended to be a higher rate of perioperative complications than the IWP group (8.2% versus 4.1%, P=0.07). Conclusions At 1 year, both SA and IA showed acceptable results for femoropopliteal chronic total occlusion lesions. Cumulative 1-year incidence of restenosis was not significantly different between SWP and IWP, whereas perioperative complications occurred more frequently in SWP than in IWP. Registration URL: https://www.umin.ac.jp; Unique identifier: UMIN000020472.

Transcatheter arterial embolization in gastric cancer patients with acute bleeding.

The safety and clinical effectiveness of transcatheter arterial embolization for bleeding associated with unresectable gastric cancer was evaluated. Twenty-three patients with bleeding from unresectable gastric cancer underwent transcatheter arterial embolization. Of the 23 patients, eight showed signs of active bleeding, such as contrast extravasation or pseudoaneurysm, seven showed only tumor staining, and the remaining eight patients showed negative angiographic findings. All embolization procedures were successful without procedure-related complications. In all eight active bleeding patients, immediate hemostasis was achieved. The overall clinical success rate was 52% (12/23). Recurrent bleeding within 1 month occurred in one (8%) in 12 patients with initial clinical success. One patient showed partial splenic infarction after embolization of the splenic artery for active bleeding from the short gastric artery. Overall 30-day mortality rate was 43% (10/23). The median overall survival period was 38 days. In patients with bleeding from unresectable gastric cancer, transcatheter arterial embolization was found to be safe and effective for achieving immediate hemostasis for active bleeding. Although the clinical success rate was not high, the recurrent bleeding rate was low at 1 month post procedure.

Enhanced Thrombolysis by Ultrasound-Assisted Catheter-Directed Thrombolysis and Microbubbles in an In Vitro Model of Iliofemoral Deep Vein Thrombosis.

There is a need to improve the efficacy and safety of catheter-directed thrombolysis (CDT) for thrombo-occlusive diseases, and ultrasound-assisted CDT (USAT) is a promising approach. We tested if thrombolysis efficacy of USAT can be improved by adding gaseous microbubbles (MB). We developed an in vitro dynamic overflow model for iliofemoral deep vein thrombosis, and added MB to an USAT system with ultrasound energy and dose of tissue plasminogen activator according to clinical practice. A total of 64 clots (mean baseline weight of 8.23 ± 1.12 g, generated from citrated human whole blood from 7 healthy male volunteers) were randomly assigned to 1 of 4 study protocols of 30 minutes' duration: negative control, CDT, USAT, and USAT + MB.Thrombolysis efficacy was assessed by measuring the change in D-dimer levels in the overflow liquid and the percentage of clot weight reduction. Compared to negative control, change in D-dimer increased by 62% (p = 0.017), 128% (p = 0.002), and 177% (p < 0.001) in the CDT, USAT, and USAT + MB groups, respectively. D-dimer increase was greater in the USAT than in the CDT group (p = 0.014), and greater in the USAT + MB than in the USAT group (p = 0.033). Compared to negative control, percentage of clot weight reduction increased by 123% (p = 0.016), 154% (p = 0.002), and 233% (p < 0.001) in the CDT, USAT, and USAT + MB groups, respectively. Percentage of clot weight reduction was greatest in the USAT + MB group (p < 0.05 compared with all other groups). In conclusion, our in vitro study suggests that the thrombolytic efficacy of USAT in human whole blood clots can be improved by local administration of MB.

Curious case of a true aneurysm of the lateral femoral circumflex artery: a rare but important differential in the diagnosis of a painless groin mass.

A 60-year-old man, presented with a 3-month history of a painless, non-pulsatile firm mass in the left groin. He was referred to sarcoma clinic for a biopsy following MRI and B mode ultrasound (US). This was abandoned when colour flow US imaging revealed the mass more in keeping with a pseudoaneurysm rather than malignancy. He was then referred to the vascular team for further investigation, where CT angiography revealed a large and thrombosed true aneurysm of his left femoral circumflex artery. This was treated with open surgical repair. Technical challenges included an adherent femoral nerve, which was carefully dissected off the aneurysm before the aneurysm was ligated and resected. An uneventful recovery followed with discharge within 48 hours. Follow-up duplex US scan revealed patent arteries with no further abnormalities.

Schwannoma of thigh mimicking pseudoaneurysm of the profunda femoral artery.

Femoral and popliteal artery aneurysms constitute the majority of peripheral arterial aneurysms. However, aneurysm of the profunda femoral artery is highly uncommon, being mainly of traumatic and mycotic origin. Diagnosis is usually straightforward with clinical and radiological examination, and such aneurysms are only rarely misdiagnosed as tumors. We herein report a case of preoperatively diagnosed pseudoaneurysm of the profunda femoral artery that was intraoperatively found to be a soft tissue tumor and finally revealed to be a schwannoma, by pathology. Our case's unusual presentation considerably confounded both diagnosis and management, thus providing a salutary clinical lesson.

[Prophylaxis of thrombotic complications of reconstructive interventions for occlusion of the main arteries of femoral-popliteal segment].

Comparative evaluation of effectiveness of the usage of the Pentosan polysulfas SP 54 and low molecular heparins after reconstructive interventions by the patients with occlusion of the main arteries of femoral-popliteal segment for the prevention of postoperative thrombotic complications was held. The obtained results show the great hypocoagulation and hypocholesterol effect of Pentosan polysulfas SP 54, and the expediens its application in that patients.

Impact of stent diameter on vascular response after self-expanding paclitaxel-eluting stent implantation in the superficial femoral artery.

BACKGROUND: The optimal sizing of self-expanding paclitaxel-eluting stents (PES) in the treatment for superficial femoral artery (SFA) lesions is unclear. This study sought to investigate the influence of PES diameter on stent patency in SFA lesions using optical frequency domain imaging (OFDI). METHODS: A total of 20 de novo SFA lesions were randomized 1:1 to receive either self-expanding PES with a nominal diameter of 6mm or 8mm. Follow-up angiography and OFDI was scheduled six months after stent implantation, and volumetric OFDI analysis was performed to evaluate vascular response to the stents. Volume index (VI) was defined as the volume divided by the stent length. The primary end point was lumen VI at the 6-month follow-up. Secondary end point was minimum lumen diameter (MLD) by quantitative vascular angiography (QVA) at the follow-up. RESULTS: Stent length was 78.0±23.9mm in the 6-mm group and 70.0±23.6mm in the 8-mm group (p=0.46). Baseline QVA data were also similar between the two groups. MLD immediately after stent implantation was similar between the two groups (4.2±0.5mm in the 6-mm group and 3.9±0.5mm in the 8-mm group, p=NS). At the 6-month follow-up, MLD was greater in the 8-mm group compared to the 6-mm group (4.0±1.0mm vs. 3.2±0.4mm, p<0.05). Stent VI was larger in the 8-mm group (28.4±6.7mm3/mm vs. 22.2±1.2mm3/mm, p=0.01). Neointimal VI was similar between the two groups (5.8±2.9mm3/mm vs. 5.2±2.6mm3/mm, p=0.68). Lumen VI was greater in the 8-mm group (23.2±7.6mm3/mm vs. 17.3±2.6mm3/mm, p=0.04). CONCLUSIONS: Chronic stent enlargement resulted in greater lumen area after implantation of self-expanding PES with a large diameter at the mid-term follow-up. Stent diameter might be important for stent patency in procedure with PES for SFA lesions.

Pseudoaneurisma de artéria femoral comum em paciente covid19: relato de caso / Pseudoaneurysm of the common femoral artery in a covid-19 patient: case report / Pseudoaneurisma de la arteria femoral común en un paciente con covid-19: estudio de caso

Introdução: O pseudoaneurisma pode ser definido como um hematoma pulsátil resultante de uma laceração de uma artéria em que há extravasamento de sangue contido pelos tecidos circunvizinhos. Dessa forma, cria-se uma comunicação entre a artéria e uma cavidade, que receberá fluxo sistólico. As principais etiologias incluem traumas, pós procedimento, pós cirurgia vascular e infecções. Objetivo: Relatar o caso de uma paciente com pseudoaneurisma de artéria femoral, durante quadro de COVID-19. Método: Relato de caso baseado na análise de prontuário médico, exames de imagem e revisão da literatura. Relato de caso: Apresentamos uma paciente do sexo feminino, com 79 anos, com diagnóstico de pseudoaneurisma em Artéria Femoral Comum após realização de cateterismo arterial e durante quadro de COVID-19. No pós operatório, paciente evoluiu com deiscência e necrose da ferida operatória. Conclusão: A escolha cirúrgica foi eficaz e relativamente segura. Uso de aparato cirúrgico específico para a paciente positiva para COVID-19 foi necessário. A evolução complicada da ferida operatória possui associação ao crescimento de bactérias multirresistentes devido à internação e ao estado geral grave pós COVID-19.(AU)

Introduction: The pseudoaneurysm can be defined as a pulsatile hematoma resulting from a laceration of an artery in which there is extravasation of blood contained by the surrounding tissues. This creates a communication between the artery and a cavity, which will receive systolic flow. The main etiologies include trauma, post-procedure, post-vascular surgery and infections. Objective: To report the case of a patient with pseudoaneurysm of the femoral artery, during COVID-19. Materials and Methods: Case report based on medical record analysis, imaging tests and literature review. Case report: We present a female patient, aged 79, diagnosed with pseudoaneurysm in Common Femoral Artery after arterial catheterization and during COVID-19. In the postoperative period, the patient evolved with dehiscence and necrosis of the operative wound. Conclusion: The surgical choice was effective and relatively safe. Use of specific surgical apparatus for the patient positive for COVID-19 was necessary. The complicated evolution of the surgical wound is associated with the growth of multidrug-resistant bacteria due to hospitalization and severe general condition after COVID-19.(AU)

Introducción: El pseudoaneurisma se puede definir como un hematoma pulsátil resultante de la laceración de una arteria en la que hay extravasación de sangre contenida por los tejidos circundantes. De esta forma, se crea una comunicación entre la arteria y una cavidad, que recibirá el flujo sistólico. Las principales etiologías incluyen trauma, post-procedimiento, post-cirugía vascular e infecciones. Objetivo: Reportar el caso de un paciente con pseudoaneurisma de la arteria femoral durante la COVID-19. Método: Reporte de caso basado en análisis de historias clínicas, pruebas de imagen y revisión de la literatura. Caso clínico: Presentamos una paciente de 79 años diagnosticada de pseudoaneurisma en la arteria femoral común tras cateterismo arterial y durante la COVID-19. En el postoperatorio la paciente evolucionó con dehiscencia y necrosis de la herida quirúrgica. Conclusión: La elección quirúrgica fue efectiva y relativamente segura. Fue necesario el uso de aparato quirúrgico específico para el paciente COVID-19 positivo. La complicada evolución de la herida quirúrgica se asocia al crecimiento de bacterias multirresistentes por la hospitalización y el grave estado general tras la COVID-19.(AU)