Pirogoff amputation is a viable option to maintain ambulation in chronic limb-threatening ischemia with extensive midfoot tissue loss: a report of two cases.

Eliminating necrotic and infected tissues is crucial for limb salvage in patients with chronic limb-threatening ischemia (CLTI). However, extensive lesions that involve the midfoot frequently result in transtibial amputation, restricting ambulation and independent life. The Modified Pirogoff amputation, which includes a 90° rotation of the calcaneus and fixation with the tibia, has good functional outcomes in trauma cases. Here, we report two patients with CLTI successfully managed by a combination of revascularization and modified Pirogoff amputation, resulting in preserved ambulation without a prosthesis. Modified Pirogoff amputation may be a good alternative in revascularized CLTI with extensive tissue loss of the midfoot.

Successful treatment of a patient with a 'flow-through' type II endoleak associated with an aberrant renal artery after endovascular aneurysm repair.

Identification and control of responsible feeding arteries are crucial in treating type II endoleaks after endovascular aortic repair (EVAR). A 78-year-old female patient required management of a type II endoleak 8 years after EVAR. A persistent endoleak from the inferior mesenteric artery (IMA) enlarged the size of an aneurysm sac. Sac angiography from the IMA revealed a flow-through endoleak from the IMA to an aberrant renal artery (ARA). After coil embolization of the ARA through the sac together with the IMA, the sac shrank. Control of flow-through vessels may be essential for managing post-EVAR enlargement due to type II endoleaks.

The Infrapopliteal Global Limb Anatomic Staging System Predicts Wound Healing and Pain Relief after Partial Revascularization.

BACKGROUND: Chronic limb-threatening ischemia (CLTI) is frequently associated with crural artery occlusion. Complete revascularization beyond the diseased crural artery is preferable; however, complete revascularization is challenging in many cases for various reasons. On the other hand, partial reconstruction for inflow disease sometimes leads to complete relief of symptoms. It is not elucidated which patients may recover from CLTI with partial revascularization (PR). Therefore, we aimed to evaluate the factors affecting outcomes after PR. METHODS: We retrospectively reviewed the medical records of patients who underwent first-attempt PR, for CLTI, for limb salvage, in our institution, between April 2012 and December 2020. We divided these 103 cases into 2 groups: the salvage group (who achieved wound healing or relief from rest pain with PR; n = 81) and the nonsalvage group (who ended with major amputation or additional distal revascularization; n = 22). We evaluated the factors affecting the outcome of PR in terms of patient risk, limb severity (Society for Vascular Surgery Lower Extremity Threatened Limb Classification System; wound, ischemia, and foot infection [WIfI] classification), and anatomical pattern (Global Limb Anatomic Staging System; GLASS classification). RESULTS: Although patient risk between the 2 groups was not statistically significant, hypoalbuminemia (< 3.0 mg/dL) was more prevalent in the nonsalvage group without significance (P = 0.068). Regarding limb severity status, there was no significant difference in WIfI grades. Wound grade showed the strongest correlation (P = 0.11) and reduced wound grade suggested future wound healing. In terms of GLASS, infrapopliteal grade was statistically significant (P = 0.033). Upon a multivariate analysis, among infrapopliteal grade, hypoalbuminemia, and wound grade, infrapopliteal grade (P = 0.0096) and hypoalbuminemia (P = 0.2512) revealed significant differences. Wound grade also showed correlation (P = 0.085). CONCLUSIONS: The usefulness of the WIfI classification and GLASS classification to predict wound healing after PR for CLTI was validated.

Long-Term Outcomes following Common Femoral Endarterectomy.

Thromboendarterectomy of the common femoral artery (CFA) for occlusive disease is a crucial procedure in vascular surgery. As an outcome reference for emerging endovascular procedures and new devices, we need more robust evidence of the outcome of this gold standard technique. The purpose of this study was to report 10-year results after femoral endarterectomy (FEA). A retrospective review of medical records at our institution identified eighty consecutive patients (91 limbs) who underwent FEA for CFA lesions. Indications for FEA included 50 limbs (55%) for intermittent claudication (IC) and 39 limbs (43%) with chronic limb-threatening ischemia (CLTI). Two limbs (2%) underwent FEA to prevent hemodynamic steal during extra-anatomical bypass. Adjunctive procedures included endovascular therapy in 32%. CFAs were closed with patch angioplasty in 44%. With a mean follow-up period of 39 months, the survival rates at 3 and 8 years were 85% and 77%, respectively. Limb salvage rates were 92% and 87%. Primary patencies were 98% and 84%. Freedom from target lesion revascularization was 95% at 3 years and 91% at 8 years. Our findings support the durability of FEA, with comparable long-term procedural results in CLTI patients as well as IC patients. Since the FEA is a gate maneuver for hybrid revascularization in CLTI patients, our findings support a strategy combining open and endovascular approaches. Femoral endarterectomy remains a durable solution for common femoral occlusive disease in IC and CLTI in the era of endovascular therapy.

Prediction Models for Two Year Overall Survival and Amputation Free Survival After Revascularisation for Chronic Limb Threatening Ischaemia.

OBJECTIVE: The aim of this study was to create prediction models for two year overall survival (OS) and amputation free survival (AFS) after revascularisation in patients with chronic limb threatening ischaemia (CLTI). METHODS: This was a retrospective analysis of prospectively collected multicentre registry data (JAPAN Critical Limb Ischaemia Database; JCLIMB). Data from 3 505 unique patients with CLTI who had undergone revascularisation from 2013 to 2017 were extracted from the JCLIMB for the analysis. The cohort was randomly divided into development (2 861 patients) and validation cohorts (644 patients). In the development cohort, multivariable risk models were constructed to predict two year OS and AFS using Cox proportional hazard regression analysis. These models were applied to the validation cohort and their performances were evaluated using Harrell's C index and calibration plots. RESULTS: Kaplan-Meier estimates of two year OS and AFS post-revascularisation in the whole cohort were 69% and 62%, respectively. Strong predictors for OS consisted of age, activity, malignant neoplasm, chronic kidney disease (CKD), congestive heart failure (CHF), geriatric nutritional risk index (GNRI), and sex. Strong predictors for AFS included age, activity, malignant neoplasm, CKD, CHF, GNRI, body temperature, white blood cells, urgent revascularisation procedure, and sex. Prediction models for two year OS and AFS showed good discrimination with Harrell's C indexes of 0.73 (95% confidence interval [CI] 0.69 - 0.77) and 0.72 (95% CI 0.68 - 0.76), respectively CONCLUSION: Prediction models for two year OS and AFS post-revascularisation in patients with CLTI were created. They can assist in determining treatment strategies and serve as risk adjustment modalities for quality benchmarking for revascularisation in patients with CLTI at each facility.

Health Related Quality of Life Over Time After Revascularisation in Patients With Chronic Limb Threatening Ischaemia.

OBJECTIVE: Chronic limb threatening ischaemia (CLTI) decreases life expectancy and impairs health related quality of life (HR-QOL). Revascularisation is needed to relieve ischaemia and salvage limbs. Although a major goal of CLTI treatment is maintaining QOL, little information is available about changes of HR-QOL over time after revascularisation. HR-QOL with survival after revascularisation for CLTI was assessed. METHODS: The clinical database of the Surgical reconstruction versus Peripheral INtervention in pAtients with critical limb isCHemia (SPINACH), a prospective multicentre observational study, was analysed. Outcome measures were disease specific QOL per the Vascular Quality of Life (VascuQOL) questionnaire and the Short Form (SF) 36 evaluated generic QOL, which were assessed at baseline and three, 12, 24, and 36 months. The outcome measure was change of QOL from baseline. The minimally important difference (half a standard deviation from baseline) was used as the cut off point for improved, worsened, and unchanged QOL. RESULTS: Overall QOL was improved in 61% of patients for the VascuQOL and approximately 40% for the SF-36 component summaries at three months. However, these proportion gradually decreased to 21% - 31% at three years. In contrast, the proportion of deceased patients gradually increased over the three year follow up. Multivariable analysis revealed that pre-operative non-ambulatory status was inversely associated with improved QOL for the three month VascuQOL and SF-36 mental component summary, and surgical reconstruction was positively associated with these measurements. Advanced age and renal failure were inversely associated with improved QOL for the SF-36 mental component summary and VascuQOL at one to three years. CONCLUSION: Revascularisation improved QOL. However, patients with non-ambulatory status exhibited a negative association with improved QOL at three months, and advanced age and renal failure limited benefits one to three years after revascularisation. Accumulating QOL data will be essential for post-revascularisation QOL estimation. Pre-operative assessment, including estimated QOL, is important in shared decision making for patient oriented outcomes in the treatment of CLTI patients.

Ruptured tibial artery in neurofibromatosis type 1: A case report.

INTRODUCTION: Neurofibromatosis type 1 (NF-1) or von Recklinghausen's disease, an autosomal dominant genetic disorder, is characterized by a café au lait spot and cutaneous neurofibromas. It typically involves the skin, nerves, bones, muscles, and eyes, and occasionally involves vascular complications and can lead to life-threatening hemorrhage. CASE PRESENTATION: We present the case of a 77-year-old female with a posterior tibial artery rupture with NF-1. She presented with sudden right lower leg swelling, pain, paresthesia, and paralysis; computed tomography images revealed popliteal artery aneurysm with surrounding hematoma, expanding from the posterior aspect of the knee to the calf. Diagnosed with compartment syndrome, due to a ruptured right popliteal artery aneurysm, she underwent prosthetic replacement of the popliteal aneurysm. Intraoperatively, the fragility of the popliteal artery was noted, although no perforation site was recognized despite the aneurysm; active bleeding originated from the hematoma between the calf muscles. Intraoperative digital subtraction angiography revealed an extravasation at the branch of the posterior tibial artery that was managed by coil embolization of the posterior tibial artery. CLINICAL DISCUSSION: Although the frequency of NF-1 vasculopathy is unknown, vasculopathy is the second most common cause of mortality in patients with NF-1, after malignancy. The less invasive endovascular approach might be preferable for treating NF-1-related aneurysm. The NF-related vasculopathy lesion sites are diverse, and intraoperative angiography would help confirm the diagnosis. CONCLUSION: NF-1-related vasculopathy may be associated with vascular fragility, and the endovascular approach might be preferable. Endovascular-first approach could have helped in correct diagnosis in the present case.

Relationship between the Controlling Nutritional Status Score and Infrainguinal Bypass Surgery Outcomes in Patients with Chronic Limb-threatening Ischemia.

Objective: We investigated the association between Controlling Nutritional Status (CONUT) scores and the outcomes of bypass surgery in patients with chronic limb-threatening ischemia (CLTI). Methods: We retrospectively calculated preoperative CONUT scores in 118 patients (127 limbs) with CLTI who underwent infrainguinal bypass surgery. Survival, graft patency, and limb salvage were compared between the high and low CONUT score groups based on the respective cutoff points. Results: The median and mean CONUT scores were 5 and 4.8, respectively. The postoperative survival rate was lower in the high CONUT score (3-12) group than in the low CONUT score (0-2) group (P=0.0043). The limb salvage rate after arterial reconstruction was also significantly lower in the high CONUT score (8-12) group than in the low CONUT score (0-7) group (P=0.0009). Conclusions: The CONUT score can predict infrainguinal bypass surgery outcomes in patients with CLTI. (This is a translation of J Jpn Coll Angiol 2020; 60: 35-41.).

Short interposition with a small-diameter prosthetic graft for flow reduction of a high-flow arteriovenous fistula.

OBJECTIVE: The objective of this study was to evaluate the outcome of a short interposition using a small-diameter prosthetic graft as a flow-limiting procedure to manage symptomatic high-flow arteriovenous fistula (AVF). METHODS: A retrospective review of medical records on a case series was conducted. From June 2004 to April 2017, there were 25 patients with clinical symptoms of high output cardiac failure and progressive dilation of aneurysmal fistula vein due to high-flow AVF (≥1.5 L/min) who underwent short interposition with a 5-mm prosthetic graft at Saitama Medical Center. The primary outcome was the relief of clinical symptoms; other outcome measures included technical success, surgical complications, patency of vascular access, and postoperative changes in local and systemic hemodynamics as assessed by Doppler ultrasound. RESULTS: Twenty-five patients underwent short interposition for cardiac indications (n = 16) and aneurysmal dilation (n = 9). The technical success rate was 100%. The clinical symptoms were relieved in 24 patients (96.0%). Mean reduction in access blood flow was 52.4%. Cumulative primary unassisted patency rates (± standard error) at 1 year, 2 years, and 3 years were 76.2% ± 9.3%, 70.4% ± 10.3%, and 58.1% ± 11.6%, respectively. Secondary patency rates (± standard error) at 1 year, 2 years, and 3 years were 81.8% ± 8.2%, 71.5% ± 9.9%, and 71.5% ± 9.9%, respectively. Complications included access occlusion due to late thrombosis (n = 5 [21.7%]) and graft infection (n = 1 [4.3%]) in the median follow-up period of 3.9 years. CONCLUSIONS: Short interposition with a prosthetic graft is a simple, effective, and durable treatment option for end-stage renal disease patients with cardiac symptoms and progressive dilation of the fistula vein due to high-flow AVF, offering clinical symptom resolution while preserving the autologous behavior of the initial access.

Angiosome～From the Standpoint of Bypass Surgery.

Although several studies showed that angiosome-guided endovascular treatment improved wound healing and major amputation rates in patients with chronic limb-threatening ischemia (CLTI), effectiveness of the angiosome concept to the treatment of ischemic foot remains to be elucidated, especially in bypass surgery. Arterial anatomy of the foot and ankle shows that there are multiple supplementary circulation including arterial-arterial connections and choke nexus, which indicates angiosome concept may carry limited importance in bypass surgery for CLTI. On the other hand, patients with diabetes or renal dysfunction have partial occlusion of arterial-arterial connections and, therefore, quite a few patients with CLTI in Japan may present with limited but impaired supplementary circulation around the ankle. This article reviews the arterial anatomy and circulation of the foot and ankle and discusses availability and limitations of angiosome-guided bypass surgery.

Sarcopenia as a Possible Negative Predictor of Limb Salvage in Patients with Chronic Limb-Threatening Ischemia.

Objective: Open revascularization of the lower extremity in patients with chronic limb-threatening ischemia (CLTI) does not guarantee limb salvage. Due to the high prevalence of frailty among these patients, we hypothesized that sarcopenia negatively affects limb prognosis. Methods: Seventy-five CLTI patients who underwent open revascularization between 2011 and 2015 were retrospectively reviewed. The lumbar psoas index, which is the ratio of the cross-sectional area of the psoas major muscles to the patients' height squared, was used as a surrogate marker for sarcopenia. Male and female patients were stratified separately according to lumbar psoas index values. The lower two-thirds of the population for each sex were defined as the sarcopenia group, with the higher third defined as the non-sarcopenia group. Results: Comorbidities and ambulatory status did not differ between the sarcopenia (n=50) and non-sarcopenia (n=25) groups. The sarcopenia group had significantly lower overall survival rates than the non-sarcopenia group (60% vs 87% at 3 years, P<0.05). Moreover, the limb salvage rates were significantly lower in the sarcopenia group than in the non-sarcopenia group (73% vs 100% at 2 years, P<0.05). Conclusion: Sarcopenia, as measured by the lumbar psoas index, may predict poor limb prognosis in CLTI patients undergoing open revascularization.

Transposed Brachial-Basilic Arteriovenous Fistula for Vascular Access in Japan.

As more than 320,000 patients are currently receiving hemodialysis treatment in Japan, the creation and maintenance of hemodialysis access is a major concern. The national guidelines recommend autogenous arteriovenous hemodialysis, and the brachial-basilic arteriovenous fistula has been the focus of attention, because the need for secondary, tertiary, or even more vascular access is growing. Although favorable results have been reported in terms of patency and access-related complication, this fistula involves various unsolved or controversial issues, with limitations including complex procedures, which might contribute to the lower prevalence at this point in Japan. This review addresses those issues and discusses the role of fistula in Japan.

Structural analysis of adventitial collagen to feature aging and aneurysm formation in human aorta.

OBJECTIVE: Adventitial collagen structure provides the aorta with tensile strength. Like other collagen-rich tissues, it can be affected by internal factors including aging and location. We determined whether the structural characteristics of human aortic adventitial collagen change with aging, location, and aneurysm formation. METHODS: Nonatherosclerotic nonaneurysmal (NANA) human abdominal aortas were collected from 15 individuals who had died of noncardiovascular diseases (<40 years old, NANA young, n = 5; >60 years old, NANA old, n = 5). The architecture of adventitial collagen in the aortas was assessed by scanning electron microscopy, and fiber orientation was assessed by polarized microscopy with two-dimensional fast Fourier transform. We then analyzed retardation as an anisotropic property of adventitial collagen by polarized light microscopy. The orientation and retardation of NANA aortas were compared with those of abdominal aortic specimens from patients who were surgically treated for abdominal aortic aneurysm (AAA) (>60 years old, n = 11). RESULTS: Adventitial collagen of the abdominal aortas on scanning electron microscopy images appeared as wavy, ropy fibers in aortas from young individuals (NANA young, n = 5) and were essentially flattened in those from older patents (NANA old, n = 5) and from those with AAA. Collagen fibers were thicker but sparser in the adventitia of aortas with AAA. Orientation maintained in the collagen fibers of NANA aortas (n = 15) on two-dimensional fast Fourier transform analysis was unrelated to either location or age and did not differ between NANA aortas and those with AAA. However, collagen fibrils in NANA aortas (n = 15) were significantly less retarded only at the level of the inferior mesenteric artery compared with other aortic locations. In addition, retardation was significantly reduced in abdominal aortas with AAA at the level of the inferior mesenteric artery. CONCLUSIONS: The basic structure of adventitial collagen fiber was maintained in abdominal aortas regardless of location or age. Because the molecular structure at the subfibril level changed at abdominal aorta and enhanced in aortas with AAA, alterations in the molecular structure of adventitial collagen might be associated with aneurysmal formation.

Family history of aortic aneurysm is an independent risk factor for more rapid growth of small abdominal aortic aneurysms in Japan.

OBJECTIVE: We aimed to investigate risk factors associated with more rapid growth of abdominal aortic aneurysms (AAA) <50 mm (small AAAs) in Japan. METHODS: We retrospectively investigated the clinical data of 374 patients with small AAAs (maximum diameter, ≤50 mm) who were referred to The University of Tokyo Hospital, Tokyo Medical University Hospital, or Saitama Medical Center, between 1995 and 2008. RESULTS: A total of 374 patients (321 men and 53 women) were followed up for a median of 66 months. The median diameter on initial examination was 40 mm, and the median growth rate of the AAAs was 2.1 mm/y. The growth rate of AAAs with an initial diameter ≥45 mm was significantly greater than those with an initial diameter <45 mm (3.3 mm/y vs 2.0 mm/y, respectively; P = .007). The growth rate of AAAs was significantly greater in patients with hypertension than in those without (2.3 mm/y vs 1.7 mm/y, respectively; P = .006) and in patients with a family history of aortic aneurysm than in those without (4.2 mm/y vs 2.0 mm/y, respectively; P = .009). Logistic regression analysis revealed that a large initial diameter and family history of aortic aneurysm were independent predictors of accelerated growth rate of small AAAs in Japan. CONCLUSIONS: In the present study, a large initial diameter and family history of aortic aneurysm were independent risk factors for more rapid growth of small AAAs. Although few studies have reported similar findings thus far, family history of aortic aneurysm should be carefully considered during follow-up of patients with small AAAs.

Pancreaticoduodenal artery aneurysm formation with superior mesenteric artery stenosis.

Celiac stenosis or occlusion is attributed partly to increase blood flow at pancreatic arcade from the superior mesenteric artery (SMA) system and may play a causal role in true aneurysm of pancreaticoduodenal artery (PDAA) formation. However, despite possible increased blood flow in the pancreatic arcades like celiac stenosis, PDAAs with a stenotic SMA are extremely rare, with only three cases have been reported in the literature. We report a case of PDAA with SMA stenosis and review the literature.