Paradigm Shift of Interventional Strategies and Outcomes for Acute Limb Ischemia Post-Pandemic.

PURPOSE: We performed a large-scale comparison of patients treated for acute limb ischemia (ALI) in the pre-COVID (2017-2019) and COVID (2020-2022) eras to evaluate changes in interventional strategies and compare factors associated with adverse outcomes. We sought to characterize patient outcomes in an evolving ALI treatment algorithm in response to pandemic-associated presentation delays and rapid technological advancements in mechanical thrombectomy (MT). METHODS: Using the TriNetX global research network, we conducted a multicenter query across 80 health care organizations (HCOs) spanning 4 countries for patients treated for ALI. Propensity score matching was performed to account for comorbidities. Risk of adverse outcomes within 30 days was calculated for each era, including re-intervention (RI30), major/minor amputation, and death. Patients were then stratified by initial intervention: open revascularization (OR), MT, or catheter-directed thrombolysis and adjunctive endovascular procedures alone (CDT/EP). Risk of adverse outcomes was compared between treatment groups of the same era. RESULTS: After propensity score matching, the pre-COVID era and COVID era cohorts included 7344 patients each. COVID era patients experienced a statistically significant higher risk of 30-day mortality (RR=1.211, p=0.027). Mechanical thrombectomy interventions were performed more frequently in the COVID era (RR=1.314, p<0.0001). Comparing outcomes between treatment groups, MT patients required RI30 more than OR patients (pre-COVID: RR=2.074, p=0.006; COVID: RR=1.600, p=0.025). Open revascularization patients had higher 30-day mortality (pre-COVID: RR=2.368, p<0.0001; COVID: RR=2.013, p<0.0001) and major amputations (pre-COVID: RR=2.432, p<0.0001; COVID: RR=2.176, p<0.0001) than CDT/EP. Pre-COVID CDT/EP patients were at higher risk for RI30 (RR=1.449, p=0.005) and minor amputations (RR=1.500, p=0.010) than OR. The MT group had higher major amputation rates than CDT/EP (pre-COVID: RR=2.043, p=0.019; COVID: RR=1.914, p=0.007). COVID-era MT patients had greater 30-day mortality (RR=1.706, p=0.031) and RI30 (RR=1.544, p=0.029) than CDT/EP. CONCLUSION: Significant shifts toward an MT-based approach have been observed in the last 3 years. Although MT required more RI30 than OR, there was no associated consequence of mortality and limb salvage. The increased mortality seen among COVID-era patients could be explained by delayed presentation, as well as poorly understood pro-thrombogenic or pro-inflammatory mechanisms related to the first waves of COVID. More research is necessary to determine an optimal treatment algorithm. CLINICAL IMPACT: Comorbid risk factors and severity of ischemia must be carefully considered before selecting an interventional strategy to prevent adverse outcomes and maximize limb salvage. Open revascularization strategies are associated with increased mortality and limb loss compared to less-invasive thrombolytic therapy alone. Mechanical thrombectomy (MT)-based approaches have been increasingly used in the last 3 years. Patients receiving MT are more likely to require reintervention within 30 days.

Management of mobile thrombus of the thoracic aorta.

Mobile thrombus of the nonaneurysmal, nonatherosclerotic aorta is a rare condition but presents with catastrophic embolic events. We describe two cases that demonstrate differences in presentation and treatment strategies. We review the literature to discuss initial management as well as surgical options. However, due to the limited number of cases, no definitive guidelines for management exist.

Hybrid endovascular exclusion of a bleeding innominate artery pseudoaneurysm in a patient with no open surgical options.

Mycotic pseudoaneurysms (MPs) rarely affect the aortic arch vessels and usually require surgical resection for definitive treatment. In this case, a 58-year-old woman developed a bleeding innominate artery MP after primary lung cancer resection complicated by an infected chest wound. Because of her previous surgery, irradiation, and chest wall reconstruction, she was not a candidate for open resection. A hybrid endovascular approach successfully excluded her innominate artery MP through placement of an aortic arch stent graft. Cerebral circulation was maintained through a periscoped left common carotid artery stent graft to the descending thoracic aorta graft, which supplied a left-to-right carotid-carotid bypass.

Bilateral lower extremity acute thromboembolism as first presentation for cancer in a child: an interesting report.

Although it rarely occurs in children, acute arterial thromboembolism can cause significant morbidity and mortality. Rapid diagnosis and prompt treatment can increase the chances of survival with a functional limb. We describe the case of a 10-year-old boy with acute bilateral lower extremity ischemia due to arterial thromboemboli originating from a rare cancer. We discuss diagnosis of and treatment strategies for acute arterial thromboembolism in the pediatric population, as well as the rare cancer the patient was diagnosed with.

External compression of the superior mesenteric artery by the median arcuate ligament.

The median arcuate ligament can compress the proximal portion of the celiac artery causing symptoms of chronic mesenteric ischemia. This rare condition typically affects young women and often poses a diagnostic challenge. Compression of the superior mesenteric artery (SMA) in addition to the celiac artery represents an unusual variant of median arcuate ligament syndrome (MALS). We present a case of MALS resulting predominantly from external compression of the SMA. Diagnostic and therapeutic options are discussed.

Ultrasound accelerated catheter directed thrombolysis for pulmonary embolus and right heart thrombus secondary to transvenous pacing wires.

Acute pulmonary embolism is associated with a significant number of deaths each year, which are commonly attributed to deep venous thrombosis of the lower extremity. Pulmonary embolism due to right-sided cardiac thrombus associated with transvenous wires is a rare occurrence. Treatment considerations have been systemic anticoagulation with heparin or systemic thrombolytic therapy. A unique case of a patient with symptomatic PE and extensive atrial and ventricle thrombus formation associated with transvenous pacing wires treated with ultrasound accelerated catheter directed thrombolysis is presented.

Statin therapy--Part II: Clinical considerations for cardiovascular disease.

3-Hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, commonly known as statins, are the medical treatment of choice for hypercholesterolemia. In addition to achieving a therapeutic decrease in serum cholesterol levels, statin therapy appears to promote pleiotropic effects that are independent of changes in serum cholesterol. These cholesterol lowering and pleiotropic effects are beneficial not only for the coronary circulation, but for the myocardium and peripheral arterial system as well. Patients receiving statin therapy must be carefully monitored, however, as statins potentially have harmful side effects and drug interactions. This article is part II of a 2-part review, and it focuses on the clinical aspects of statin therapy in cardiovascular disease.

Percutaneous recanalization of the occluded iliac artery: examples, techniques, and complications.

Recanalization of an occluded iliac artery represents a technically challenging endovascular technique. Prior to attempting recanalization, the operator must have an approach in mind and understand the risks and complications associated with this endeavor. In this article, the authors provide 2 cases and review the techniques and complications associated with iliac artery recanalization.

Exteriorization and control of a retained embolization coil in the carotid artery--a case report.

Advances in endovascular technology have enabled the development of complex techniques for the treatment of vascular conditions. Not surprisingly, the modern vascular surgeon will likely encounter unusual complications and will need to formulate plans for their management. In the current case report, the vascular surgery service was consulted to assist in the management of a retained embolization coil in the carotid artery. Relevant aspects of detachable coils are discussed and the successful management of this potentially hazardous complication is described.

Combined endovascular and surgical repair of a large traumatic pseudoaneurysm of the thigh-a case report.

Thigh pseudoaneurysms are rare compared to pseudoaneurysms of the groin, and usually result from direct injury to an arterial branch. Direct open repair can be associated with a large volume blood loss. The authors describe a combined endovascular and surgical approach to a large, traumatic, pseudoaneurysm of the thigh. The patient was a 49-year-old man with a history of left femur fracture treated by open reduction and internal fixation, who presented with a painfully swollen left thigh. Duplex ultrasound and computed tomography (CT) scan suggested a large (7.7 x 5.0 x 6.3 cm) pseudoaneurysm that appeared to be associated with a branch of the deep femoral artery. In the operating room, angiography was used to identify and selectively access the feeding artery. This artery was then successfully coil embolized, allowing surgical decompression of the thigh with minimal effort and blood loss. Endovascular and surgical therapy were complementary in successfully treating a large traumatic pseudoaneurysm of the thigh.

Surgical thrombectomy and transluminal balloon angioplasty for failed above-knee femoropopliteal polytetrafluoroethylene bypass grafts.

Endovascular therapy offers an alternative to redo bypass or surgical graft revision for failed above-knee femoropopliteal PTFE bypass grafts. We evaluated the outcome of surgical thrombectomy and balloon angioplasty for the treatment of thrombosed bypass grafts. Thirty selected patients with thrombosed above-knee femoropopliteal PTFE bypass grafts were treated. Under local anesthesia, a surgical thrombectomy followed by bypass graft angiography and balloon angioplasty of perianastomotic stenoses was performed. Stents were used selectively for suboptimal angioplasty results. Patients underwent duplex scanning of the bypass graft postoperatively and at 6-month intervals. Life-table analysis and log-rank (Mantel-Cox) comparisons were performed. Patients were categorized into two groups on the basis of time elapsed from initial bypass graft construction to graft failure. Group 1 included 21 patients with a mean time to graft failure of 10 months (range, 0-20). Surgical thrombectomy was successful in 20 grafts (95%) and 17 patients had a stent placed after angioplasty. Rethrombosis occurred within 30 days in seven grafts (33%) in group 1 and major amputations were performed in six patients (28%). Group 2 included nine patients with a mean time to initial bypass graft failure of 48 months (range, 29-96). All patients in group 2 had a successful surgical thrombectomy and all received a stent. None of the grafts treated in group 2 reoccluded within 30 days of intervention and one patient (11%) went on to require a major amputation. By life-table analysis, the 6- and 12-month patency for group 1 was 15.3% and 5.1%, compared to 58.3% and 38.9% for group 2 (p = 0.027). Surgical thrombectomy along with balloon angioplasty has an unacceptably high rate of failure and limb loss in patients treated for early (<2 years) femoropopliteal PTFE bypass graft thrombosis. Surgical graft revision or redo bypass is recommended to achieve successful revascularization in these patients. Treatment with surgical thrombectomy and balloon angioplasty achieves significantly greater short-term patency results in patients with late (>2 years) bypass graft failure and may be a reasonable alternative for patients who cannot tolerate reoperation or lack autogenous conduit.

Hemodynamic outcome of endovascular therapy for TransAtlantic InterSociety Consensus type B femoropopliteal arterial occlusive lesions.

OBJECTIVE: Endovascular therapy for moderate femoropopliteal arterial occlusive disease remains controversial. This study reviewed our experience with endovascular therapy for TransAtlantic InterSociety Consensus (TASC) type B disease, which is defined as multiple stenoses less than 3 cm in diameter or a single stenosis or occlusion 3 to 5 cm in diameter. Stenosis-free patency was used as an objective end point to evaluate the hemodynamic outcome. METHODS: A retrospective review was performed of all patients who had undergone endovascular treatment of TASC type B lesions between 1997 and 2002 at two referral centers. Balloon angioplasty was performed in all patients. Stenting was used selectively as an adjunct in patients with suboptimal angioplasty results. The treated sites were examined with duplex ultrasound scanning at 6-month to 12-month intervals. Stenosis-free patency was defined as the absence of stenosis greater than 50% diameter in the treated arterial segment with standard duplex criteria. RESULTS: One hundred fifteen limbs in 98 patients were studied. The indication for treatment was claudication in 92 patients (80%) and ischemic rest pain or gangrene in the remaining patients (20%). Multiple lesions greater than 3 cm were treated in 89 limbs (77%), and a single lesion 3 to 5 cm long was treated in 26 limbs (23%). Balloon angioplasty alone was performed in 74 limbs (65%), and angioplasty and adjunctive stenting was performed in 41 limbs (35%). Endovascular therapy was technically successful in all but one patient (99%), and there was no perioperative mortality or limb loss. During follow-up recurrent stenosis was detected in 46 limbs (40%), and reocclusion occurred in 11 limbs (10%). Seven patients (6%) underwent surgical bypass after endovascular treatment failure. The aggregate 1-year stenosis-free patency rate at life table analysis was 55.1%. The 1-year stenosis-free patency for angioplasty alone was 58%, compared with 51% (NS) for angioplasty and adjunctive stenting. Univariate regression analysis failed to demonstrate a difference in stenosis-free patency for demographic variables, medical comorbidities, and anatomic characteristics (multiple vs single lesions; number of angioplasty procedures). CONCLUSIONS: Endovascular therapy for TASC type B femoropopliteal lesions is safe and technically feasible. However, the length of time that a treated arterial segment remains free of stenosis is limited, and is not improved with adjunctive stenting. Recurrent stenosis, not occlusion, was the most common study end point, and few patients subsequently required surgical bypass. Predictors of outcome after endovascular therapy for TASC type B lesions were not identified in this study.

Endovascular repair of a penetrating thoracic aortic ulcer by way of the carotid artery.

INTRODUCTION: Endovascular repair of thoracic aortic lesions offers an attractive alternative to traditional open repair. Access to the thoracic aorta can occasionally be challenging because of large device size and vessel tortuosity. Traditional access by way of the femoroiliac vessels might not be possible in the setting of synchronous iliac occlusive disease. MATERIALS AND METHODS: A 63-year-old woman presented with a 7.1-cm symptomatic, penetrating ulcer of the descending thoracic aorta. The patient's severe pulmonary disease prohibited an open repair. A Talent endoprosthesis was placed under compassionate use with approval of the institutional review board. The graft was placed by way of the left common carotid artery because of severe iliac occlusive disease. RESULTS: The thoracic endograft was successfully placed with exclusion of the pseudoaneurysm. The patient's chest pain resolved immediately. She developed mild left-sided weakness from a postoperative right anterior cerebral artery stroke that quickly resolved. The patient was discharged on postoperative day 5. No aortic endoleak was noted on follow-up computerized tomography scan at 1 month. CONCLUSIONS: Endovascular repair should be considered in patients with thoracic aortic aneurysms, particularly those with severe medical comorbidities. Placement by way of the common carotid artery is technically feasible in the setting of synchronous aortoiliac disease.