Kidney transplantation reduces the risk of chronic limb threatening ischemia and amputation among patients with end-stage renal disease on hemodialysis.

OBJECTIVE: This study aimed to analyze the risk of chronic limb threatening ischemia (CLTI) or amputation among patients with end-stage renal disease (ESRD) entering a hemodialysis (HD) program and to evaluate the protective effect associated with kidney transplantation (KT). DESIGN, MATERIAL AND METHODS: Retrospective cohort of all consecutive ESRD patients entering into a HD program at our institution between 2000 and 2010. Collected variables included baseline characteristics (pre-entry in hemodialysis), time on HD program, KT and the composite outcome of chronic limb threatening ischemia or need for any amputation (CLTI/AMP). Patients with previous symptomatic peripheral arterial disease or amputation were excluded. RESULTS: The study group included 336 patients (mean age 63 years, 66% male). The mean follow up was 6.7 years with an average time on HD of 4.2 years. Ninety two patients (27.4 %) underwent transplantation. CLTI free survival rates were 90.3 % and 82.6 % at 5 and 10 years, respectively. The episodes of CLT involved 28 revascularization procedures (17 endovascular and 11 open surgeries), 18 minor amputations and 20 major amputations. KT was associated with a protective effect over the development of CLTI (HR: 0.065; CI 95% 0.02-0.21) after adjustment for confounding factors. The long-term survival of non-transplanted patients was 45 % and 15 % at 5 and 10 years, respectively and the long-term survival in transplanted patients was 89% and 80% at 5 and 10 years, respectively; but decreased to 47 % at 1 year and 18.2 % at 5 years once CLTI occurred. CONCLUSION: Patients on HD program show a notorious risk of chronic limb threatening ischemia or amputation over time. Once this complication occurs, patient's survival is markedly reduced. Transplantation confers an independent protective effect over the development of chronic limb threatening ischemia or amputation.

Clinical Clues for the Current Diagnosis of Acute Lower Limb Ischemia: A Contemporary Case Series.

BACKGROUND: Acute lower limb ischemia (ALI) is a limb and life-threatening condition whose treatment largely depends on the underlying cause. The clinical distinction between the main causes may have changed over the years because of changes in the epidemiology of this syndrome. The objective of this study was to determine the clinical pattern associated with the main causes of ALI in a contemporary series of cases. METHODS: We retrospectively reviewed all consecutive ALI cases admitted to a tertiary hospital between 2007 and 2019. ALI secondary to other conditions than embolism or NAT were excluded. The association between clinical variables and the ALI cause was assessed with multiple logistic regressions and the discriminative power of the resulting clinical predictive scores with the area under the ROC curve. RESULTS: The study group included 243 patients (mean age 77.2 years; 52.7% male), of which 140 (57.6%) were caused by an arterial embolism and 103 (42.4%) by a NAT. Among these latter, 78 (75.7%) were related to an atherosclerotic NAT and 25 (24.3%) to a complicated popliteal aneurysm. Independent risk factors associated with embolism included atrial fibrillation (OR 10.26, 95% CI 5.1 - 20.67) or female gender (OR 5.44, 95% CI 2.76 - 10.71), but not the severity of the episode or the presence of contralateral pulses. Those related to a NAT included a previous symptomatic peripheral arterial disease (OR 2.68, 95% CI 1.35 - 5.35) and seeking consultation more than 24 hours after the beginning of symptoms (OR 2.57, 95% CI 1.32 - 5), but not a higher rate of other vascular risk factors. Among patients with NAT, previous intermittent claudication (OR 8.34, 95% CI 2.42 - 28.72) and >24 hs delay of arrival of the patient (OR 4.78, 95% CI 1.48 - 15.43) were more frequent among those related to an atherosclerotic NAT, whereas higher hemoglobin levels (OR 1.60, 95% CI 1.21 - 2.11) and non-significantly the history of tobacco smoking (OR 2.95, 95% CI 0.84 - 10.36) among those with a popliteal aneurysm-related NAT. The discriminative power of the two clinical models resulting from these predictive variables for differentiating embolism from NAT and atherosclerosis-related NAT from popliteal aneurysm-related NAT was excellent (0.86 and 0.85, respectively). CONCLUSION: Certain clinical features appear to be no longer useful in the distinction between embolism and NAT, while others may help in the differential diagnosis between atherosclerotic and popliteal aneurysm-related NAT. Surgeons must be aware of possible changes in the presentation of ALI because time constraints are frequent and clinical data remain essential.

Are continued policies of prioritizing native vascular access in patients on hemodialysis programs useful?

The guidelines recommend establishing native vascular access as opposed to prosthetic or catheter-based access despite information relating to its effectiveness being scarce from a patient-orientated perspective. We analyzed the effectiveness of a continued policy of native vascular access (CPNVA) in patients undergoing hemodialysis. A retrospective, observational study, including 150 patients undergoing hemodialysis between 2006 and 2012 at our center, and who underwent a CPNVA. Statistical analysis was based on treatment intention. In 138 patients (92%), the first useful access (FUA) was native, and in 12 patients (8%), it was prosthetic. In 50 patients (33.3%), more than one procedure had to be carried out in to order to achieve FUA. The probability of dialysis occurring via a FUA was 67.1% and 45.3% at 1 and 5 years respectively. Over the follow-up period (mean time = 30 months), 84 patients (56%) required repairs or new access, extending the effectiveness of the CPNVA to 88.3% and 73.2% at 1 and 5 years respectively. The effectiveness of the CPNVA was reduced if the patient: required a catheter initially (HR: 3.6, p = 0.007); in cases of initially elevated glomerular filtration rate (HR: 1.1, p = 0.040); in cases of history of previous access failure before FUA (HR: 3.9, p = 0.001); and in female patients (HR: 2.4, p = 0.031). The long-term effectiveness of a CPNVA is high. However, the percentage of patients requiring diverse procedures in order to achieve FUA and the need for re-interventions yield the necessity to optimize preoperative evaluation and postoperative follow-up.

Usefulness of red cell distribution width to predict mortality in patients undergoing endovascular repair of abdominal aortic aneurysms.

BACKGROUND: Red cell distribution width (RDW) reflecting impaired erythropoyesis, has been associated with poor prognosis and mortality in several conditions. The aim of this study was to determine the relationship between RDW and the 5-year survival after the endovascular repair of abdominal aortic aneurysms (EVAR) and its ability to improve the discriminative power of a survival predictive score. METHODS: Retrospective analysis of 284 patients undergoing EVAR at a single centre. The pattern of relationship between RDW and survival was assessed with penalized smoothing splines. Categorized RDW values were added to a predictive score based in standard preoperative variables, whose improvement in discriminative power was calculated on the basis of changes in the C-statistics and the continuous Net Reclassification Index (c-NRI). RESULTS: The survival rate at 5 years was 66.2% and was independently associated with hemoglobin (HR=0.85, P<0.004), statin intake (HR=0.54, P<0.004), heart failure (HR=2.53, P<0.018), atrial fibrillation (HR=2.53, P<0.000) and the non-revascularized coronary artery disease (HR=2.15, P<0.005). The relationship between RDW values and 5-year survival was linear. RDW-CV and RDW-SD were categorized to cut-off values of ≥15% (N.=83, 29.2%) and ≥50 fL (N.=82, 28.9%) that were independently associated with poorer 5-year survival rates (HR=2.03, CI 95%=1.29-3.19, P=0.002 and HR=1.89, CI 95%=1.21-2.95, P=0.005, respectively). The addition of the RDW CV or the RDW-SD to the baseline predictive score significantly improved the c-NRI (0.437, P<0.001 and 0.442, P<0.001, respectively). CONCLUSIONS: High preoperative RDW levels were linear and adversely related to 5-year survival after EVAR, improved the discriminative power of a predictive score based in standard preoperative variables and may help in decision-making at the time of surgical planning.

Outcome of elective endovascular repair of abdominal aortic aneurysms in octogenarians.

AIM: The need to adjust the indications of elective abdominal aortic aneurysm (AAA) repair among patients with a limited life-span deserves a specific evaluation for octogenarians. The aim of this study was to compare the postoperative results and the long-term survival after endovascular repair of abdominal aortic and/or iliac aneurysms (EVAR) in octogenarians compared with patients under 80 years of age. METHODS: Retrospective analysis of 241 consecutive patients who underwent an elective EVAR between 2000 and 2017. EVAR was not considered among patients with clear life-limiting conditions. Patients receiving other than commercially standard infra-renal endoprostheses were excluded. RESULTS: Seventy patients (29.0%) were octogenarians. They had a lower rate of active smoking (10.0% vs. 30.4%, P < 0.001) and a higher prevalence of previous cerebrovascular disease (21.4% vs. 11.7%, P = 0.055) than younger patients. Thirty-day/in-hospital complication and mortality rates were not significantly higher among octogenarians when compared with younger patients (24.3% vs. 16.9% and 2.9% vs. 2.4%, respectively). Octogenarians had a lower long-term survival at 1, 3 and 5 years (92.6% vs. 93.3%, 67.7% vs. 78.0% and 39.3% vs. 60.6%, P = 0.039) in the bivariate analysis. However, an age ≥ 80 years per se was not an independent predictor of survival after adjustment for confounding factors. CONCLUSION: An age above 80 years was not associated with an increased risk of postoperative complications or long-term mortality. Our results suggest that EVAR can be considered in elderly patients without a clear life-limiting condition and with a suitable aneurysm anatomy. Geriatr Gerontol Int 2021; 21: 392-397.

Natural History After Below-knee Amputation: Analysis of Survival and Prosthetic Fitting Over 2 Decades. / Historia natural del paciente sometido a una amputación infracondílea: análisis de la supervivencia y protetización durante 2 décadas.

INTRODUCTION: This study sought to evaluate the natural history of patients undergoing below-knee amputation (BKA) and compare their evolution over 2 decades, as well as survival predictors, prosthetic fitting, and contralateral amputation. METHODS: Retrospective study of 209 consecutive patients (mean age 72.9 years; 68% males) who underwent BKA in 2 periods: 1996-2005 and 2006-2015. The fitting of prostheses, risk of contralateral amputation and survival, as well as their predictive factors, were assessed by survival analysis. RESULTS: 133 BKA were performed from 1996-2005 and 106 from 2006-2015. The etiology that motivated the BKA was acute ischemia (4.3%), chronic ischemia (34.0%), infection (9.1%) or mixed (chronic+infection, 52.6%), with no differences found between periods. Survival: mortality within one month=9.2%, one year=31.9%, 2 years=43.8% and 5 years=63.9%, with no significant differences between the 2 periods. Prosthetic: the fitting rate was 44.5% throughout the follow-up, with no significant differences between the two periods. 41.1% patients managed to walk. Contralateral amputation: 20.1% of the patients later required a major contralateral amputation, with no significant differences between the two periods. CONCLUSIONS: In the last decade, fewer BKA have been performed probably, due to higher previous interventional revascularization. Despite this, the results of fitting, contralateral amputation or survival were not modified. In any case, the number of patients who are able to achieve ambulation is modest, so it emphasizes the need for an optimal selection of patients with BKA with the goal of prosthetic fitting.

Utility of doppler ultrasound in the preoperative evaluation of the first vascular access for haemodialysis. / Utilidad de la valoración ecográfica previa a la realización del primer acceso vascular para hemodiálisis.

INTRODUCTION: Traditionally, the indication of the type of vascular access (VA) has been based on the surgeon's physical examination, but it is now suggested that imaging methods could provide a clinical benefit. Our aim was to determine whether or not preoperative Doppler ultrasound modifies outcomes of the first VA for haemodialysis. PATIENTS AND METHODS: Prospective cohort of patients undergoing a first VA from June 2014 to July 2017 who had a preoperative Doppler ultrasound (ECO group). They were compared to a historical cohort (January 2012-May 2014) of first VA indicated exclusively by clinical assessment (CLN group). RESULTS: A total of 86 patients from the CLN group were compared to 92 from the ECO group, which was younger (68.4 vs 64.0, P=.038). The primary patency (CLN/ECO) at 1 and 2years was 59.5%/71.9% and 53.1%/57.8% respectively, marginally better in the ECO group (P=.057). The assisted patency at 1 and 2years was 63.2%/80.7% and 58.1%/70.2%, respectively, significantly better for the ECO group (P=.010). Due to lack of patency/utility of the initial VA, 26.7% in the CLN group and 7.6% in the ECO group (P<.001) required a new VA during the first 6months. An average of 1.39 interventions were performed to achieve a useful VA in the CLN group and 1.08 in the ECO group (P<.001), the first VA being useful at the radiocephalic level in 31.0%/45.1% (P=.039). CONCLUSION: The indication of the first VA according to a preoperative Doppler ultrasound examination could decrease the need for new VA, enable them to be made more distal, and significantly improve patency.

Predictive factors of a poor outcome following revascularization for critical limb ischemia: implications for practice.

BACKGROUND: Advancements in open and endovascular techniques have brought a widespread indication of revascularization in the majority of patients with critical limb ischemia (CLI). However, some cases still have a dismal short-term outcome. Identifying preoperative variables that characterize these patients could be important to prevent futile decisions. The aim of this study was to define predictive risk factors of mortality and/or major amputation after revascularization for CLI. METHODS: Retrospective study of 515 consecutive patients (mean age=73 years; 73% males) undergoing open (N.=228; 44.3%) or endovascular (N.=287; 55.7%) surgery for CLI between 2005 and 2015. Neither redo-procedures (ipsilateral or contralateral) nor acute limb ischemia patients were included as new cases. RESULTS: Thirty-day amputation, mortality or combined event rates were 1.4% (N.=7), 4.5% (N.=23) and 5.6% (N.=29), while at 90 days were 4.1 (N.=21), 9.1% (N.=47) and 12.8% (N.=66), respectively. We found no significant differences between open or endovascular surgery. Risk factors associated with a 90-day combined event were age (OR=1.04, P=0.014), preoperative hemoglobin (OR=0.80; P=0.003), history of acute myocardial infarction (OR=2.68; P=0.007), ischemic ulcers (OR=2.57; P=0.014) and below-the-knee revascularization (OR=2.20; P=0.007). The discrimination of the model was good (area under ROC curve=0.75). Model predicted probabilities of the combined death and/or lower limb major amputation end-point ranged (95% interval) from 1.1% to 38.1%. CONCLUSIONS: Certain preoperative variables can predict satisfactorily the short-term outcome after revascularization for CLI, although they are not sufficiently useful to identify the patient in whom revascularization can be clearly futile. Further research is needed to refine a predictive model suitable for decision-making.

Acute Limb Ischemia Secondary to Native Artery Occlusion: Results of a Contemporary Case Series.

BACKGROUND: The treatment of acute limb ischemia (ALI) has barely changed over the last years. However, the progressive implementation of anticoagulants, antiplatelet agents or statins within the population might have modified the profile and prognosis of patients suffering an ALI. The aim of this study was to evaluate the current results of the management of ALI secondary to a native artery occlusion. METHODS: Retrospective study of 220 consecutive patients (mean age 78 years; 49% male) was conducted between 2007 and 2015. ALI secondary to trauma or grafts/stents occlusions were excluded. Statistical analysis was performed with logistic regression. RESULTS: A total of 141 cases (64.1%) were attributed to embolism and 79 (35.9%) to acute arterial thrombosis. Peripheral neuro-ischemic impairment occurred in 135 patients (61.4%), being severe in 42 (19.1%). ALI treatment included anticoagulation (n = 27; 12.3%), regional fibrinolysis (n = 2; 1%), embolectomy/thrombectomy (n = 129; 58.6%), angioplasty/stenting (n = 8; 3.6%), bypass (n = 47; 21.3%) or direct major limb amputation (n = 7; 3.2%). Limb salvage and survival rates at 30/90 days were 95%/95% and 82.3%/74.1%, respectively. Independent risk factors for major amputation were diabetes, severe neuro-ischemic impairment, acute arterial thrombosis and treatment delay >1 day after vascular consultation. In addition, age, chronic peripheral arterial disease, any neuro-ischemic impairment and a hospitalization for any other reason simultaneous to the ALI were independently associated with mortality. CONCLUSIONS: Regardless of excellent limb salvage rates, patients currently suffering from an ALI are, when compared to previous studies, older than before and with an increased rate of mortality. Risk factors do not appear to be modifiable once the ALI appears so prevention strategies should be aimed to avoid the episode.

[Aorto-bifermoral grafs infection due to Candida parapsilosis. An unusual pathogen]. / Infección de injerto aortobifemoral por Candida parapsilosis. Un germen inhabitual.

BACKGROUND: Aorto-enteric fistula is a rare and potentially lethal entity. Its presentation may be as an enteric-paraprosthetic fistula, due to injury in the gut caused by direct contact with the vascular prosthesis. OBJECTIVE: We report a case of enteric-paraprosthetic fistulae with the unusual finding of Candida parapsilosis as the only isolated pathogen. CLINICAL CASE: A 65-year-old male, smoker, with aortobifemoral revascularisation with dacron due to aortoiliac occlusive disease, and re-intervention for thrombosis of left arm at 6 months. Hospitalisation at 22 months was required due to a toxic syndrome, which was diagnosed as enteric-paraprosthetic fistulae after complementary studies. The graft was removed and an extra-anatomic revascularisation was performed. Microbiology specimens taken from the duodenal segment in contact with the prosthesis showed the prosthetic segment and peri-prosthetic fluid were positive to C. parapsilosis. DISCUSSION: The finding of C. parapsilosis in all cultures taken during surgery, along with negative blood cultures and no other known sources of infection, is of interest. It is an unusual pathogen with low virulence and limited as regards other Candida species. Our patient had no clinical data common to cases of infection with C. parapsilosis, and the mechanism of graft infection is unknown. CONCLUSION: Graft infection by C. parapsilosis may be anecdotal. However, its consequences can also be severe. Microbiological tests can be useful to adjust antimicrobial therapy in the post-operative period, but their usefulness for determining the aetiology is doubtful, as it may be just an incidental finding.

Predictors of medium-term patency in percutaneous endovascular therapy of femoro-popliteal lesions.

BACKGROUND: The objective is to study the medium-term results of angioplasty and stenting in the femoro-popliteal sector in patients with critical limb ischemia (CLI), and identify angiographic predictive factors of primary patency. PATIENTS AND METHODS: Retrospective review of 98 patients with critical ischemia and angiographic lesions characterized as TASC A=13 (14%), B=38 (40%), C=24 (25%) or D=20 (21%). A total of 106 angioplasties and primary self-expanding stents (mean length of stent coverage of 19cm) were performed between January 2006 and January 2011. RESULTS: The immediate results of patency, limb salvage and survival were 95, 96 and 96%, respectively. Primary patency at 1 and 2 years was 54 and 38%, respectively. Twenty-seven cases (25%) required endovascular iterative procedures, providing an assisted patency at 1 and 2 years of 72 and 60%, and a secondary patency of 80 and 67%. A lower primary patency was observed (log rank) when stent length was >20cm (P<.001), popliteal artery was invloved (P=.004), and in TASC C and D lesions (P=.04). In multivariate analysis (Cox), only stent length>20cm was an independent negative predictor for primary patency (HR=5.7, P<.001). The limb salvage at 1 and 2 years was 83 and 81%, respectively. CONCLUSIONS: Angioplasty with stent in the femoro-popliteal sector is a safe technique, but with significantly lower permeability results in injuries that require stent coverage of more than 20cm. In these cases, vein bypass surgery should be the procedure of choice.