Prediction and Management of Surgical Site Infections in Hybrid Vascular Surgery for Peripheral Artery Disease.

OBJECTIVES: Postoperative complications are an important problem that all surgeons face. Among all possible complications, local and systemic infections are one of the most prevalent postprocedural adverse events. It is difficult to assess whether or not a patient will develop a surgical site infection (SSI), but there are certain basic investigations that can suggest the probability of such an event. We also investigated some clinically assessable signs to help us better predict the occurrence of SSIs. Every bit of information brings us closer to an ideal where we can bring postoperative complications to a minimum. Close examination and attention to detail is crucial in the prediction and prevention of SSIs. Methods: A multicenter, retrospective and prospective observational study was carried out between 01.01.2019 â?" 01.09.2021. All adult patients with peripheral artery disease (PAD) who had disabling intermittent claudication or rest pain, were included in this study. We excluded minor or vascular surgery emergencies (ruptured aneurysms, acute ischemia or vascular trauma). We followed the postoperative complications as well as their management with an emphasis on surgical site infections (SSIs). Receiver Operating Characteristic (ROC) curves were used to determine key values of statistical relevance by calculating the Area Under the Curve (AUC). Multivariate analysis was used to assess the statistical relevance of our data. Results: The study evaluates 128 patients diagnosed with PAD, aged between 47 and 97, with a mean age of 71.26 Ã+- 10.8 years. There were significantly more male than female patients 71.09% vs. 28.91% (p 0.01). All patients were treated using hybrid vascular techniques. All complication rates were recorded but we focused on SSIs, which was the most prevalent complication (25%). C-Reactive Protein with values higher than 5 mg/dl, was confirmed as a positive predictive factor for postoperative surgical site infections (AUC = 0.80). Another positive predictive factor for SSIs is hyperglycemia. Glycemic values higher than 140mg/dl are more frequently associated with postoperative infections (p = 0.02), a predictability curve of statistical significance was also obtained (AUC = 0.71). Postoperative SSIs were more prevalent in patients with preoperative distal trophic lesions (p 0.01). The presence of other complications such as edema and lymphoceles were also linked to SSIs (p 0.01). Nevertheless, patients who underwent surgery over negative wound pressure therapy (NWPT) for infection management had significantly shorter hospital stays (p 0.01). Conclusions: There are multiple clinical or paraclinical predictors of SSIs. The coexistence of several such factors can carry an additional risk of developing a SSI and should be evaluated and controlled separately in the preoperative phase as much as possible. Admission to a diabetes center and regulation of glycemic values prior to elective vascular surgery, for patients who can be surgically postponed is an effective method of preventing infections. Surgical management remains the most reliable form of treatment of SSIs, being the most efficient therapy and offering immediate results, while simultaneously shortening hospital stays.

Editor's Choice - A Cost Effectiveness Analysis of Outpatient versus Inpatient Hospitalisation for Lower Extremity Arterial Disease Endovascular Revascularisation in France: A Randomised Controlled Trial.

OBJECTIVE: The AMBUVASC trial evaluated the cost effectiveness of outpatient vs. inpatient hospitalisation for endovascular repair of lower extremity arterial disease (LEAD). METHODS: AMBUVASC was a national multicentre, prospective, randomised controlled trial conducted in nine public and two private French centres. The primary endpoint was the incremental cost effectiveness ratio (ICER), defined by cost per quality adjusted life year (QALY). Analysis was conducted from a societal perspective, excluding indirect costs, and considering a one month time horizon. RESULTS: From 16 February 2016 to 29 May 2017, 160 patients were randomised (80 per group). A modified intention to treat analysis was performed with 153 patients (outpatient hospitalisation: n = 76; inpatient hospitalisation: n = 77). The patients mainly presented intermittent claudication (outpatient arm: 97%; inpatient arm: 92%). Rates of peri-operative complications were 20% (15 events) and 18% (14 events) for the outpatient and inpatient arms respectively (p = .81). Overall costs (difference: €187.83; 95% confidence interval [CI] -275.68-651.34) and QALYs (difference: 0.00277; 95% CI -0.00237 - 0.00791) were higher for outpatients due to more re-admissions than the inpatient arm. The mean ICER was €67 741 per QALY gained for the base case analysis with missing data imputed using multiple imputation by predictive mean matching. The outpatient procedure was not cost effective for a willingness to pay of €50 000 per QALY and the probability of being cost effective was only 59% for a €100 000/QALY threshold. CONCLUSION: Outpatient hospitalisation is not cost effective compared with inpatient hospitalisation for endovascular repair of patients with claudication at a €50 000/QALY threshold.

Evolution of Practices in Treatment of Abdominal Aortic Aneurysm in France between 2006 and 2015.

BACKGROUND: The main objective of this study was to identify the changes that have occurred in the treatment of abdominal aortic aneurysms (AAA) in France over a period of 10 years. MATERIALS AND METHODS: Comprehensive data for AAA surgical activity from all French health establishments between 2006 and 2015 were collected from the records of the "Agence Technique de l'Information sur l'Hospitalisation." Based on the common classification of medical procedures, our research was conducted on surgical procedures involving open and endovascular surgical treatment of AAA. A year-by-year descriptive analysis was completed for the number of procedures, the change in the type of surgery performed in each type of institution, and the mean duration of hospital stays. RESULTS: During the study period, the number of AAA treated increased overall by 28.2% (from 6,412 procedures in 2006 to 8,221 in 2015). The proportion of endovascular procedures increased in this period (from 27.0% in 2006 to 68.5% in 2015) like their number from 1,735 to 5,632. The number of fenestrated endovascular aneurysm repair (listed since 2013) increased from 251 to 373 in 3 years. Open repair decreased from 4,677 interventions in 2006 to 2,589 in 2015 with higher proportion of suprarenal clamping in open surgery (from 23% in 2006 to 40% in 2015). The number of ruptured AAA treated in open surgery remained stable over this period (473 in 2006 and 462 in 2015). CONCLUSIONS: In France, the number of AAA operated between 2006 and 2015 increased by 28.2%. There was a significant increase in endovascular techniques, which became largely predominant in 2015. In open repair, the proportion of complex procedures increased in this period. However, this transformation, which is in line with current recommendations and major publications, needs to be reassessed in the long term.

Cerebral Infarct Topography and Early Outcome after Surgery for Symptomatic Carotid Stenosis: A Multicentre Study.

INTRODUCTION: Although carotid stenosis can cause both territorial and border-zone (BZ) cerebral infarcts (CI), the influence of CI topography on postoperative complications after surgery remains unclear. We compared early outcomes after endarterectomy on the basis of CI location: territorial (T group) or BZ group. MATERIAL AND METHODS: During the period between 2009 and 2013, ischaemic stroke patients who had undergone surgery for symptomatic carotid stenosis were identified from prospective databases from 3 French centres. The outcome was the identification of a combined stroke/death rate 30 days after endarterectomy. RESULTS: Two hundred and eighty-nine patients were included, 216 (74.7%) in the T group and 73 (25.3%) in the BZ group. The mean degree of stenosis was comparable in the 2 groups (78 ± 12% in the T group vs. 80 ± 12% in the BZ group, p = 0.105), with, however, more sub-occlusions (stenosis >90%) in the BZ group (38.4 vs. 23.1%, p = 0.012). The mean time between the time CI developed and the time surgery was performed was 19.6 ± 24.8 days, with a majority of patients being operated upon within 2 weeks following the formation of CI (66.7% in the T group vs. 60.3% in the BZ group, p = 0.322). The combined endpoint was significantly more frequent in the BZ group (9.6 vs. 1.9%, p = 0.003), with 4 ischaemic strokes and 3 deaths. In multivariate analysis, BZ CI was an independent predictor of postoperative stroke or death at 30 days (HR 4.91-95% CI [1.3-18.9], p = 0.020). CONCLUSION: BZ infarcts carry a greater risk of postoperative complications after carotid surgery, thus suggesting that topography of the CI should be considered in the decision-making process regarding surgery.

Evolution of Practices in Carotid Surgery: Observational Study in France from 2006 to 2015.

BACKGROUND: The principal objective of this study is to determine the evolution of surgical management of stenosis of carotid bifurcation over a period of 10 years in France. The secondary objective is to ascertain the impact of recommendations and of the literature on the evolution of these practices. METHODS: From the registry of the "Agence Technique de l'Information sur l'Hospitalisation" we collected all the data for carotid surgery procedures carried out in French healthcare establishments between 2006 and 2015. The search was conducted using the common classification of medical procedures for open surgery and endovascular treatment, and diagnosis-related groups corresponding to neurovascular disease. We conducted a descriptive analysis of data year-by-year and analyzed the number of procedures, the evolution of the type of surgery according to the type of establishment, and the mean duration of hospital stays. RESULTS: During the study period, 165,276 classical procedures (95.8%) and 7319 endovascular procedures (4.2%) of carotid bifurcation were performed. The overall number of procedures was stable over time at a mean of approximately 17,000 procedures per year. Concerning conventional surgery, eversion endarterectomy became the main technique from 2008 onwards, superseding open endarterectomy with patch closure, whereas direct primary closure of the carotid bifurcation has been declining steadily ever since. The use of a shunt declined steadily from 16.3% in 2006 to 13.3% in 2015. Endovascular treatment progressed steadily during the study period from 455 procedures (2.7% of procedures) in 2006 to 943 procedures (5.7%) in 2015. The mean hospital length of stay for patients without associated severe comorbidity was constant for classical surgery (mean of 5.4 days). CONCLUSION: This observational analysis showed stability in the number of carotid procedures performed during the period and a progressive modification of carotid surgery practices in France, in accordance with the recommendations of learned societies and major publications.

Influence of the type of cerebral infarct and timing of intervention in the early outcomes after carotid endarterectomy for symptomatic stenosis.

OBJECTIVE: Our objectives were to compare early postoperative outcomes after carotid endarterectomy for symptomatic carotid stenosis and to analyze the impact of time to treatment between patients with a territorial or a border-zone infarct. METHODS: This is a single-center, retrospective study carried out on data from a single-center, prospective database. Patients undergoing carotid endarterectomy for symptomatic carotid stenosis after an ipsilateral acute ischemic stroke were included between January 1, 2009 and December 31, 2013. The only exclusion criterion was a mixed-topography stroke. We included 114 patients who were retrospectively divided into groups according to the location of the infarct: group TI for territorial infarction and group BZ for border-zone infarction. The primary end point was the 30-day death or stroke rate. RESULTS: Ninety patients were included in the TI group (79%) and 24 in the BZ group (21%) with a mean age of 73 ± 11 years. All demographic data were similar between the two groups except for dyslipidemia, which was greater in the BZ group (72% vs 47%, P = .03) and the subocclusive feature of carotid stenosis (14% in the TI group vs 33% in the BZ group, P .04). There was one death and one stroke in each group, with a 30-day death and stroke rate of 2% in the TI group and 8% in the BZ group (P = .18). Multivariate analysis showed that the National Institute of Health Stroke Score (NIHSS) score was the only independent predictive factor of complications with an increase of 36% per additional point in this score. Sixty-eight patients (76%) in the TI group and 14 (58%) in the BZ group were operated on during the first 2 weeks after the neurological event. In this subgroup, the 30-day death or stroke rate was 2% in the TI group (one stroke) vs 14% in the BZ group (one stroke and one death; P = .06). The preoperative NIHSS score was again the only factor significantly associated with the postoperative complication rate (P = .03). CONCLUSIONS: In our series, surgery for patients with symptomatic carotid stenosis after border-zone infarction resulted in more complications than after territorial infarction, although no significant differences were found. This study nonetheless raised questions concerning the optimal timing of carotid surgery depending on the type of the original stroke. Other larger-scale studies are necessary to determine whether the type of cerebral infarction needs to be taken into account in decisions whether to operate on the diseased carotid as early as possible.

Delay between symptoms and surgery for carotid artery stenosis: modification of our practice.

BACKGROUND: Recent data from the literature concerning symptomatic carotid stenosis show that the long-term benefits of surgery are greater when the surgery is performed soon after the neurologic event, ideally within 2 weeks. Since 2009, following recommendations, we decided to perform surgery as quick as possible. The aim of the study was to determine whether this approach increased postoperative morbimortality and the way it could change our practice. METHODS: Using a prospective database containing a consecutive and continuous series of 1,500 carotid endarterectomies performed between 2003 and 2012, we extracted the records concerning the 417 symptomatic carotid stenoses (27.8%). We compared the 30-day and long-term outcome in 3 groups of patients: those operated within 2 weeks of the neurologic event (early surgery group [ESG], n = 158, 37.9%), those operated between 16 days and 6 weeks after the event (deferred surgery group [DSG], n = 79, 18.9%), and those operated more than 6 weeks after the event (late surgery group [LSG], n = 180, 43.2%). In the second part, to assess the new management beginning 2009, patients were divided in 2 periods 2003-2008 (period A) and 2009-2012 (period B) and we compared the 2 period's descriptive data and outcome. The primary outcome was the 30-day combined stroke and death rate. Secondary end points were follow-up freedoms from mortality and stroke. RESULTS: The mean time between symptom onset and surgery was 7.7 ± 3.8 days for the ESG, 28.3 ± 8.6 days for the DSG, and 89.4 ± 36.7 days for the LSG. In the 3 groups, the types of symptoms leading to the indication for carotid surgery were comparable, with a stroke in 221 cases (53.0%), a transient ischemic attack in 146 cases (35.40%), and amaurosis fugax in 50 cases (12.0%). The groups were comparable in terms of comorbidities. The overall 30-day stroke rate was 1.4% (6 cases), the 30-day death rate was 1.7% (7 cases), and the combined stroke and death rate was 3.4% (3.2% in the ESG, 5.1% in the DSG, and 2.8% in the LSG [P = 0.808]). Survival rates at 24, 48, and 60 months were, respectively, 95%, 78%, and 78% in ESG, 86%, 81%, and 81% in DSG, and 91%, 83%, and 74% in LSG (P = 0.78). Freedom from stroke at 60 months showed to be, respectively, 97% in ESG, 96% in DSG, and 91% in LSG (P = 0.32). During the period A (2003-2008), we had taken care of 217 symptomatic carotid artery stenosis patients (22.3% of stenosis) and during the period B (2009-2012), 200 symptomatic stenosis (37.9% of stenosis). During the period A, an early surgery (<15 days) had place in 31 cases (14.3%), and during the period B, in 127 cases (63.5%). The 30-day stroke and death rate was of 3.7% during the period A and of 3.0% during the period B (P = 0.455). The 24-month survival and stroke-free survival rates were comparable between the 2 periods. CONCLUSIONS: In our experience, surgery for symptomatic carotid stenosis can be performed early without increasing the rate of postoperative and long-term outcome. We have modified our practice, performing more and more early surgery for symptomatic stenosis without any impact on the outcome.

Endovascular Treatment of Infected Brachial Pseudoaneurysm in an Intravenous Drug Abuser: A Case Report.

We report the case of a 36-year-old male, admitted in the emergency room with a nonruptured brachial pseudoaneurysm after buprenorphine injection, with no signs of distal acute ischemia. After endovascular treatment with a nitinol covered stent associated with adapted antibiotherapy and 35 days of hospitalizations, the patient was discharged with good short results but stent need to be removed at 6 months for thrombosis and partial exposure through the wound.

Development of abdominal aortic aneurysm is decreased in mice with plasma phospholipid transfer protein deficiency.

Plasma phospholipid transfer protein (PLTP) increases the circulating levels of proatherogenic lipoproteins, accelerates blood coagulation, and modulates inflammation. The role of PLTP in the development of abdominal aortic aneurysm (AAA) was investigated by using either a combination of mechanical and elastase injury at one site of mouse aorta (elastase model) or continuous infusion of angiotensin II in hyperlipidemic ApoE-knockout mice (Ang II model). With the elastase model, complete PLTP deficiency was associated with a significantly lower incidence and a lesser degree of AAA expansion. With the Ang II model, findings were consistent with those in the elastase model, with a lower severity grade in PLTP-deficient mice, an intermediate phenotype in PLTP-deficient heterozygotes, and a blunted effect of the PLTP-deficient trait when restricted to bone marrow-derived immune cells. The protective effect of whole-body PLTP deficiency in AAA was illustrated further by a lesser degree of adventitia expansion, reduced elastin degradation, fewer recruited macrophages, and less smooth muscle cell depletion in PLTP-deficient than in wild-type mice, as evident from comparative microscopic analysis of aorta sections. Finally, cumulative evidence supports the association of PLTP deficiency with reduced expression and activity levels of matrix metalloproteinases, known to degrade elastin and collagen. We conclude that PLTP can play a significant role in the pathophysiology of AAA.

Dissecting aneurysm of the celiac trunk: a case report.

Aneurysms of visceral arteries are relatively rare entities. Spontaneous isolated celiac artery dissection is an uncommon diagnosis, with only a few reported cases. We report the case of 52-year-old man who had an asymptomatic celiac trunk dissecting aneurysm detected by tomographic angiography. Because of the combined risk of rupture and ischemia, we decided to treat this lesion by a conventional bypass.

Mycotic aneurysm of both internal iliac arteries due to Candida albicans.

We report the case of a 21-year-old man, with a Candida-related endocarditis causing multiple emboli and bilateral false aneurysms of the internal iliac arteries. As the distal runoff vasculatures of both internal iliac arteries were occluded, these arteries required ligation. Although there were few consequences with the procedure, multiple emboli and recurrence of endocarditis after cardiac surgery led to the patient's death.

Risk index for predicting shunt in carotid endarterectomy.

BACKGROUND: To prevent ischemia during carotid endarterectomy, a routine or selective shunt can be set up in cases of insufficient cerebral perfusion during the carotid clamping. The aim of this study was to analyze predictive factors for shunting under locoregional anesthesia and to validate a risk index to predict shunt. METHODS: Using a prospective database, we studied carotid endarterectomy performed under locoregional anesthesia between January 1, 2003, and December 31, 2010 (n=1,223). A shunt was used because of clinical intolerance of clamping in 88 cases (group S, 7.2%). Clinical, comorbidities, demographics, and duplex scan data were used to compare group S to a control group (group C, n=1,135, 92.8%). A multivariable logistic regression was performed to identify predictors of shunt. Coefficients were assigned to each predictor to propose a predictive score. RESULTS: Patients in group S were significantly older than those in group C (75.6±7.8 years vs. 72.6±9.4 years, P<0.001). Other factors associated with a carotid shunt were female sex (odds ratio [OR]=2.41, 95% confidence interval [CI]: 1.54-3.78, P<0.001), systemic arterial hypertension (OR=2.478, 95% CI: 1.16-4.46, P=0.016), occlusion of the contralateral carotid artery (OR=6.03, 95% CI: 2.91-12.48, P<0.001), and 1 factor against the likelihood of a carotid shunt, a history of contralateral carotid surgery (OR=0.34, 95% CI: 0.12-0.93, P=0.037). The mean flow in the contralateral common carotid artery was 696.5±298.0 mL/sec in group S and 814.7±285.5 mL/sec in group C (P<0.001). Using those 6 items, we propose a prognostic score validated in our series and allowing to divided risk of intolerance of clamping into low-risk (≤6%), intermediate-risk (6.1%-15%), and high-risk (>15%) groups. CONCLUSIONS: We have established the first version of a score that predicts the need for a shunt by studying factors associated with intolerance to clamping. The relevance of this score, validated in our series, must be confirmed and adjusted by studies based on a larger sample size.

First results of clampless distal anastomosis in peripheral vascular bypass with LeGoo, a thermoreversible polymer.

BACKGROUND: We report our initial experience with LeGoo (Pluromed Inc, Woburn, Mass), a temporary thermoreversible occlusive gel, in peripheral vascular revascularization. METHODS: Between 2007 and 2010, LeGoo was used to occlude target vessels during bypass surgery in 14 patients who required infrainguinal revascularization. RESULTS: Proximal occlusion of the target vessel was obtained with a mean quantity of 0.25 mL of LeGoo. Distal occlusion of the vessel was obtained with a mean quantity of 0.28 mL. One injection of LeGoo was sufficient to prevent backbleeding in 11 of 14 patients. The mean occlusion time was 13.4 ± 3.3 minutes. An injection of saline through the graft or better directly into the arteries was used to dissolve the gel. For our first case, a Fogarty catheter was used to remove residual gel from the anterior tibial artery. CONCLUSIONS: LeGoo gel can be used to stop blood flow in small-bore arteries in the lower limbs to allow anastomoses to be performed.

Influence of the contralateral carotid artery on carotid surgery outcome.

BACKGROUND: Any obstacle in the contralateral artery has long been considered a high risk for carotid surgery. Here, we report the results of a monocentric, continuous, consecutive, prospective series and present a review of the literature. METHODS: All carotid endarterectomies performed under locoregional anesthesia in our department between 2003 and 2010 were recorded in a prospective database (n = 1,212). Different statuses of the contralateral carotid artery--occlusion (group O, n = 81) and stenosis of >60% (group S, n = 173)--were compared with a control group (group C, n = 958). A shunt was used in cases of clinical intolerance to clamping. The assessment criteria concerned the need for a shunt and the combined 30-day nonfatal stroke and death rate. A stepwise logistic regression was performed. RESULTS: Overall, a shunt was necessary in 7.3% of cases. The proportion was greater in group O (25.9%, P < 0.001). Severe renal insufficiency (odds ratio [OR] = 1.94) and contralateral carotid occlusion (OR = 5.53) were the sole factors predicting the need for shunting. The overall 30-day nonfatal stroke and death rate was 2.5%, with no difference between groups (P = 0.738), and severe renal insufficiency was the single predictor of a poor outcome (OR = 3.11; 95% confidence interval: 1.21-7.97; P = 0.18). CONCLUSION: In this series, and in a large review of literature, occlusion of the contralateral internal carotid artery increased the incidence of intolerance to clamping and thus the use of shunts but did not worsen postoperative morbidity and mortality. The presence of a stenosed contralateral carotid was not predictive of postoperative events. In our experience, the status of the contralateral carotid artery cannot be considered a high risk for carotid surgery.

Long-term results of stenting of the aortic bifurcation.

BACKGROUND: To evaluate the long-term results in a multicentric continuous series of narrowing lesions of the aortic bifurcation treated with a kissing stent. METHODS: From January, 1st 1999 to the December, 31st 2001, all of the patients (n = 80) presenting with stenosis of the aortic bifurcation (n = 15) and/or the 2 common iliac arteries (n = 65), treated with a kissing stent, in 8 teaching hospitals were collected retrospectively. The risk factors were smoking (91%), dyslipidemia (60%), arterial hypertension (42%) and diabetes (27%). In 84% of cases, the indication for treatment was claudication. The lesions were stenotic < 70% (n = 76) and/or thrombotic (n = 18). The associated lesions were external iliac stenoses (n = 21), common femoral stenoses (n = 19), femoro-popliteal stenoses (n = 42), arteriopathy in the leg (n = 35). Follow-up was clinical examination and Doppler US scan. RESULTS: The success rate of the technique was 89%. There were 4 cases (5.3%) of residual stenosis and 4 cases (5.3%) of dissection. The length of the lesions treated in the aorta and the iliac arteries was respectively 17.1 ± 7 and 17.3 ± 9 mm. The stents were all placed as kissing stents, and had a mean diameter and a mean length of 13.75 mm and 56 mm in the aorta and 9 mm and 48 mm in the iliac arteries, respectively. At 5 years, 19 patients had required repeat angioplasty in the treated area, and 13 had undergone open surgery. Primary and assisted primary patency at 5 years were 64.5% and 81.8%, respectively. CONCLUSION: Long-term follow-up of endovascular treatment with kissing stents for stenosis of the aortic bifurcation shows that this technique gives good results, though it does not justify doing away with classical revascularisation surgery, in a population with major cardiovascular risk factors.

The impact of renal insufficiency on the outcome of carotid surgery is influenced by the definition used.

BACKGROUND: Renal insufficiency (RI) seems to be a source of complications after carotid endarterectomy (CEA). However, published studies do not use a common definition of RI. Our objective was to analyze the effects of RI on carotid surgery using three classifications of renal function. METHODS: Using a prospective database, we studied renal function and postoperative complications in patients operated on between January 1, 2003 and December 31, 2008. Renal function was studied using the level of plasma creatinine, creatinine clearance calculated according to the Cockcroft formula, and to the Modification of Diet in Renal Disease (MDRD) equation. For each method, the patients were divided into three groups: normal renal function, moderate RI, and severe RI. The principal judgment criterion was the 30-day non-fatal stroke and death rate. RESULTS: The analysis concerned 961 CEAs carried out in 901 patients. The 30-day non-fatal stroke and death rate was 2%. In the analysis of renal function using the level of creatinine, there was no statistical difference between the groups in the 30-day stroke and death rate (normal renal function: 1.8%, moderate: 2.7%, severe: 8.3%, P = .21). The analysis of renal function according to creatinine clearance calculated using the Cockcroft formula showed that in the severe RI group, the stroke and death rate was higher than in the other two groups (normal renal function: 1.7%, moderate RI: 1.4%, severe RI: 7.5%, P = .004). Analysis using the MDRD formula showed similar differences between the severe RI group and the other two with a higher rate of 30-day stroke and death (normal renal function: 1.4%, moderate RI: 1.7%, severe RI: 12.5%, P < .001). Subgroup analysis showed that among patients with severe RI according to the creatinine clearance, those with symptomatic carotid stenosis had the highest incidences of non-fatal stroke and death (Cockcroft, n = 19: 21.1%, MDRD, n = 10: 40%). CONCLUSION: Severe RI is a risk factor for complications after carotid surgery. Creatinine clearance calculated according to the MDRD formula correlates most closely with these complications. Symptomatic patients with severe RI, according to the creatinine clearance, are at high risk with a very high level of postoperative complications.

Bilateral Acute Cardioembolic Limb Ischemia After Coronavirus Disease 2019 Pneumonia in a Lung Transplant Recipient: A Case Report.

Very few cases of lung transplant patients affected by coronavirus disease 2019 (COVID-19) have been reported to date. A 31-year-old patient who underwent bilateral lung transplantation for cystic fibrosis in 2012 was admitted for severe acute lower limb pain. He had a confirmed exposure to COVID-19 and a 3-week history of upper respiratory tract infection. Whole-body computed tomography (CT) angiography revealed an occlusion of the 2 common femoral arteries. CT angiography detected an intracardiac thrombus in the left ventricle. Chest CT angiography showed ground-glass opacities consistent with COVID-19. A bilateral femoral surgical embolectomy using Fogarty catheter was successfully performed. Specific reverse transcription polymerase chain reaction for severe acute respiratory syndrome coronavirus 2 performed on an extracted thrombus was negative, but IgM antibodies specific for COVID-19 were detected. Cardiac magnetic resonance imaging demonstrated a subendocardial and almost transmural late gadolinium enhancement in the mid and distal inferolateral and inferior wall segments, consistent with a nonrecent myocardial infarction and an apical centimetric thrombus adjacent to the lesion. Thrombophilia laboratory tests found the presence of a positive lupus anticoagulant. Treatment with low-molecular-weight heparin and aspirin was prescribed. On day 13, the patient was discharged from the hospital. This case underlines the need to be vigilant with respect to the thrombotic complications of COVID-19 and raises the issue of thrombosis prevention in COVID-19 patients.

Role for endovascular therapy in chronic mesenteric ischemia.

Chronic mesenteric ischemia is a rare condition that is caused by stenosis or occlusion of the mesenteric arteries and usually manifests as abdominal pain. While surgical revascularization has been the standard treatment for symptomatic patients, recent advances in interventional devices and techniques have made endovascular treatment feasible and effective. Percutaneous transluminal angioplasty with stent placement is now recognized as a minimally invasive means of obtaining good long-term results with an acceptable recurrence rate; consequently, the technique is suggested for the primary treatment of chronic mesenteric ischemia. The present article discusses the indications and principles of endovascular treatment, and reviews the literature, with emphasis on short- and long-term outcomes, particularly morbidity and mortality rates.