Mid-term Outcomes of Image-Guided Surgical Thromboembolectomy and Routine Intraoperative Angiography for Native Vessel Acute Lower-Limb-Threatening Ischemia.

BACKGROUND: Standard balloon-catheter thromboembolectomy (TE) is an established effective treatment for acute lower-limb ischemia (ALI) with recognized limitations when there is an underlying arterial lesion or thromboembolism of the infrapopliteal arteries. The aim of this study was to evaluate the efficacy and safety of image-guided surgical TE combined with routine intraoperative completion angiography in the treatment of ALI patients. METHODS: Between September 2020 and August 2022, this prospective study included all consecutive adult patients presenting to a tertiary center with unilateral ALI of Rutherford class II due to thromboembolic occlusion of native arteries who underwent image-guided surgical TE and routine completion intraoperative angiography. Adjunctive endovascular techniques (hybrid revascularization) including plain balloon angioplasty (PTA)±stenting or on-table lysis were used if underlying arterial lesions or residual thrombosis were detected on the intraoperative angiography, respectively. The primary outcome measures included technical success and 30-day major amputation rate. Perioperative complications, 1-year primary and secondary patency, limb salvage, mortality, and amputation-free survival rates were endorsed as secondary outcome measures. RESULTS: Image-guided surgical thrombectomy was done for 109 ALI patients (109 limbs), provisionally diagnosed as embolic (57 patients, 52.3%) or thrombotic (52 patients, 47.7%) arterial occlusion. Thromboembolectomy without adjunctive endovascular treatment was done in 38 patients (34.86%), whereas 71 patients (65.14%) required adjunctive PTA±stenting of underlying arterial lesions (60, 55.05%) or on-table lysis±PTA of residual thrombosis (11, 10.09%). The overall technical success rate was 92.66%. At 30 days, amputation and mortality rates were 3.67% and 5.5%, respectively. None of the patients had thrombectomy-induced arterial injuries. One-year follow-up data were available for 81 patients (74.3%). The Kaplan-Meier estimate of the 12-month primary and secondary patency, limb salvage, and amputation-free survival rates was 76.5%±0.04, 91.5%±0.03, 90.6±0.03, and 91.4±0.03%, respectively. CONCLUSIONS: Image-guided TE combined with routine intraoperative angiography is a safe and effective technique for surgical TE in acute lower-limb ischemia patients with the advantage of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. CLINICAL IMPACT: The present study has confirmed the safety and effectiveness of image-guided thromboembolectomy combined with routine use of intraoperative angiography during surgical treatment of acute lower limb ischemia in terms of immediate identification and treatment of underlying arterial lesions or residual thrombosis for optimal revascularization. This technique also facilitates selective passage of Fogarty balloon catheter into infrapopliteal arteries from the femoral approach which is traditionally done by exploration of the popliteal trifurcation or tibial arteries under regional or general anesthesia. Using this technique can guide the operating surgeon for adequate balloon manipulation and inflation to avoid iatrogenic vessel injury.

The Untold Story: Early and Mid-Term Results of Subintimal Angioplasty in Superficial Femoral Artery Versus Popliteal Artery Chronic Total Occlusion.

OBJECTIVES: This study aims to compare the immediate and mid-term outcomes of subintimal angioplasty (SIA) of chronic total occlusions (CTOs) of superficial femoral artery (SFA) versus popliteal artery (PA) and to identify possible predictors of loss of limb-based patency (LBP). METHODS: This is a retrospective analysis of chronic lower-limb ischemia (CLI) patients (Rutherford classes 3-6) presenting with CTO of SFA or PA treated by SIA and selective stenting in the period 2018 to 2021. Immediate outcomes were compared between the SFA and PA groups, including technical success, perioperative complications, and 30-day major amputation and mortality rates. Mid-term outcomes for technically successful procedures included limb-based patency (LBP), wound healing rate, amputation-free survival (AFS), and major adverse limb events (MALEs). RESULTS: A total of 450 CLI patients underwent SIA of CTO at the SFA (n=260, 57.8%) and the PA (n=190, 42.2%). The indication for revascularization was chronic limb-threatening ischemia in 80.8% of SFA group and 84.2% of PA group. Technical success rate was higher in the PA group compared to the SFA group (96.3% vs 91.2%; p=0.03). The 30-day amputation rates were comparable between the SFA and PA groups (7.7% vs 6.8%, p=0.7, respectively). No perioperative mortality or systemic major complications occurred in the present study. Kaplan-Meier estimate of the 1-year rates were significantly better for SFA group regarding LBP (82% for SFA group vs 43% for PA group, p=0.006), AFS (88% vs 64%, p=0.02), and wound healing (79% vs 58%, p=0.027), respectively. The number of runoff vessels was the only factor associated with loss of LBP (hazard ratio [HR], 0.055; 95% confidence interval [CI]: 0.001-3.020, p=0.039). CONCLUSIONS: Subintimal angioplasty is an effective and safe endovascular treatment option of CTO at SFA and PA with satisfactory immediate outcomes. The mid-term outcomes, however, are better for SFA lesions in terms of improved LBP, AFS, and wound healing rates. CLINICAL IMPACT: Subintimal angioplasty is a valuable tool in the armamentarium of endovascular surgeons, as re-entry devices aren't always widely accessible. This study aims to assess the technical outcomes of peripheral vascular interventions for infrainguinal chronic total occlusions and identify possible predictors for successful subintimal angioplasty .Subintimal angioplasty is an effective treatment option for infrainguinal CTO with difference in result of immediate outcomes in popliteal lesions and SFA lesions.

Addressing the Impact of Deep Venous Stenting on the Management of Venous Ulcer.

BACKGROUND: Venous ulcers are a late and severe form of chronic venous insufficiency and account for 70% of all etiologies that cause leg ulcers in the lower limb, and they account for 20% of the 2.5 million cases complaining of chronic venous disease. Our study aims to investigate the effect of venous stenting of the deep veins on the healing of the venous ulcer. METHODS: This is a single-center, retrospective study conducted on prospectively recorded medical records of 78 patients with chronic deep venous diseases-C6 (either nonocclusive iliac venous lesion or post-thrombotic syndrome). Our lesion involved May-Thurner lesions, occlusions, insufficiencies, or stenoses owing to an affection of the venous outflow segment. All our patients underwent endovascular management, and those who did not respond successfully were transitioned to compression therapy. We then compared the outcomes of both groups in terms of ulcer healing and quality of life. RESULTS: A total of 78 patients (78 limbs), with a mean age of 39.6 ± 8.06 (range: 22-60) years, were treated. Fifty-four patients (67.9%) were males, and 24 (32.1%) were female. The etiology was primary nonocclusive iliac venous lesion in 12 limbs (16.2%) and secondary post-thrombotic obstructions in 66 (83.7%). Follow-up of the ulcer with compliance to compression therapy and standard care of the ulcer, sustained ulcer healing (reduction in ulcer area) was achieved in 60% of limbs, and most of the nonocclusive healing occurred within the first 3 months (P < 0.01). CONCLUSIONS: Our results show that deep venous stenting is associated with high wound healing rates. This rate reaches a statistically significant difference in 3 months, but this difference doesn't reach statistical significance at 6 months, with less recurrence and improved quality of life with a high cumulative patency rate, and compression therapy is the mainstay of the conservative management of venous ulceration.

Can wound blush be used as an indicator for termination of endovascular procedures in chronic limb-threatening ischemia patients?

INTRODUCTION: Predicting the outcomes of endovascular revascularization of chronic limb-threatening ischemia (CLTI) patients with foot wounds can be challenging. Angiographic wound blush (WB) assessment has been found to be a helpful tool to assess wound perfusion. The aim of this study is to evaluate WB during endovascular revascularization of CLTI patients and its effects on treatment outcomes. METHODS: This prospective study included all CLTI patients with foot wounds who underwent successful endovascular revascularization of infrainguinal arterial disease between 2019 and 2021. Patients were grouped according to the WB status into positive WB (group A) and negative WB (group B). Both groups were compared for demographics, comorbidities, clinical picture, and 12-month limb-based patency (LBP) and amputation-free survival (AFS) rates. RESULTS: The study included 69 patients of Rutherford classes 5 (46.4%) and 6 (53.6%), with the main arterial lesion located at the femoropopliteal (58%) or infrapopliteal (42%) segments. Completion angiography showed positive WB in 38 (55.1%) patients and negative WB in 31 (44.9%) patients. Both groups were comparable regarding patient presentation, site of the main arterial lesion, and distribution of foot lesions in relation to the feeding artery. The overall 12-month LBP and AFS rates were 21.7% and 39.1%, respectively, with significantly better rates in group A than in group B (LBP, 31.6% vs 9.7%, p = 0.001 and AFS, 54.1% vs 22.2%, p = 0.006, respectively). Successful angiosome-based direct flow to the foot was achieved in 38 patients (55.1%), resulting in significantly better 12-month AFS rates than those with indirect revascularization (54.8% vs 26.3%, p = 0.036, respectively), despite the comparable 12-LBP rates between the direct and indirect revascularization groups (29% vs 15.8%, p = 0.133, respectively). Multivariate logistic regression analysis identified smoking as a significant predictor of a major amputation, whereas positive WB and successful direct revascularization were significant predictors of limb salvage. CONCLUSIONS: WB can serve as a predictor for AFS and LBP during endovascular revascularization of CLTI patients with foot wounds. A positive WB may guide the decision to conclude an endovascular procedure, potentially avoiding unnecessary complicated maneuvers to recanalize more vessels. Conversely, a negative WB may suggest the need for further revascularization attempts to augment wound perfusion and healing.

The Relationship Between the Global Limb Anatomic Staging System and Midterm Outcomes of Subintimal Angioplasty of Superficial Femoral Artery Atherosclerotic Disease in Chronic Limb Threatening Ischemia.

BACKGROUND: Superficial femoral artery (SFA) is commonly affected with atherosclerotic peripheral arterial disease leading to chronic limb-threatening ischemia (CLTI). Subinitimal angioplasty (SIA) is a minimally invasive option. We aimed to examine the relationship between the Global Limb Anatomic Staging System and SIA midterm limb and survival-related outcomes. METHOD: A prospective observational study was conducted on all patients with CLTI (Rutherford 4-6 or WIFI stages 2-4), with diseased femoropopliteal segment underwent SIA from August 2020 to September 2021. Patients with non-atherosclerotic SFA occlusion and those requiring primary major amputation were excluded. Multivariable Cox proportional hazard regression was performed to assess possible predictors of midterm clinical outcomes. Kaplan-Meier survival curves were used to estimate limb-based patency (LBP), limb salvage, amputation-free survival (AFS), and overall survival. RESULTS: The study included 138 patients with CLTI due to chronic total occlusion of the SFA and underwent SIA ± treatment of associated ipsilateral hemodynamically significant inflow/outflow disease. Primary technical success was achieved in 116 cases (84%), with primary patency at 1, 6, and 12 months being 100%, 84%, and 79% respectively, while the limb-salvage rate at 6 and 12 months was 100% and 94%, respectively. The result of the comparison between CLASS 1 and Global Limb Anatomic Staging System III (GLASS III) revealed significantly worse patency with GLASS III (p=0.005), and better overall survival (p=0.037), limb salvage (p=0.021), and AFS (p<0.001) with GLASS I. CONCLUSION: Subinitimal angioplasty is a safe, effective, and minimally invasive treatment option for lengthy SFA lesions by avoiding the patients' anesthesia and operative risk. Our study suggests that the GLASS stage may be a useful predictor of midterm limb and survival-related outcomes of this approach. GLASS III anatomy in comparison with GLASS I is associated with a statistically significantly worse LBP, limb salvage, AFS, and overall survival. CLINICAL IMPACT: This study is discussing a very hot interesting challenging topic in vascular surgery and its management as SFA atherosclerotic lesion is the most common lesion faced by vascular surgeons subintimal angioplasty SIA is considered feasible and effective method in dealing with this lesion with accepted durability and lower rates of complications.The subintimal angioplasty is made by opening an extraluminal track behind the intimal layer and between the media and intima of the artery surrounding atherosclerotic plaque and thrombus. Hence, the track has a low thrombus or plaque burden content, making the SIA easier than intraluminal angioplasty and with comparable results. GLASS stage III was an independent predictor of loss of LBP, worse AFS, and major amputation.

Measurement of Power Frequency Current including Low- and High-Order Harmonics Using a Rogowski Coil.

The measurement of a power frequency current including low- and high-order harmonics is of great importance in calibration as well as in testing processes. Therefore, this paper presents the measurement of the power frequency current of light-emitting diode (LED) luminaires. LED luminaires were chosen as their input current includes both low- and high-order harmonics. The measurement process depends on reconstructing an LED luminaire current without using the coil parameters. Hence, the current reconstruction process is designed to be dependent on the measured characteristics of the Rogowski coil itself considering the frequency range at which the measurement process is required. An evaluation of the proposed measurement process was theoretically and experimentally carried out. A theoretical evaluation was carried out using MATALB SIMULINK software. However, the experimental evaluation was performed by building a Rogowski coil to measure the input currents of different LED luminaires having different power ratings of 300 W, 400 W, and 600 W. The currents measured using the Rogowski coil were compared with reference currents measured using a standard measurement technique. The obtained results show the efficacy of the proposed measurement method.

Can cross-sectional imaging replace diagnostic venography in pelvic venous disorder (PeVD)?

OBJECTIVE: The primary etiology of pelvic venous disorder is multifactorial and challengeable in vascular surgery as it mandates multidisciplinary team cooperation for its evaluation and management. METHODS: All patients investigated for pelvic venous disorder in a high-volume, tertiary referral university hospital were identified and analyzed retrospectively during the period (March 2021 through September 2022). Demographic and medical data were scored. Agreement between the noninvasive modalities (computed tomographic venography [CTV] or magnetic resonance venography [MRV]) and diagnostic venography in detecting the refluxing pelvic veins was analyzed. Sensitivity, specificity, and diagnostic accuracy are also measured. No patients' treatments were reported in this study as the treatment is scheduled in other sessions in some cases and is out of the scope of this article. All patients had a diagnostic venogram regardless of the axial imaging modality. The main goal was to compare cross-sectional imaging with diagnostic venography. RESULTS: The total number of patients was 120 with a mean age of 34.4 ± 7.1 years; 86.7% were multiparous. All patients presented chronic pelvic pain with vulvoperineal and/or atypical lower limb varicosities. Then patients were divided into two groups: those with CTV and those with MRV. Sensitivity, specificity, and diagnostic accuracy of CTV were 50%, 33%, and 47% for the detection of incompetent ovarian veins, 83%, 33%, and 53% for the detection of incompetent internal iliac veins, and 50%, 40%, and 47% for the detection of incompetent pelvic plexus veins, respectively, whereas time-resolved MRV achieved sensitivity, specificity, and diagnostic accuracy of 73%, 25%, and 60% for the detection of incompetent ovarian veins, 75%, 46%, and 53% for the detection of incompetent internal iliac veins, and 67%, 33% and 60% for detection of incompetent pelvic plexus veins, respectively. CONCLUSIONS: The desire to avoid the drawbacks of diagnostic venography led to an increase in the use of noninvasive imaging modalities. Our results achieved acceptable sensitivity, specificity, and diagnostic accuracy outcomes for cross-sectional imaging with the superiority of MRV over CTV in diagnosing PCS.

Foam Sclerotherapy in Pelvic Congestion Syndrome.

Chronic pelvic pain (CPP) is a prevalent condition in middle-aged women that represents a heavy social impact on the quality of life of those females. Treatment of pelvic congestion syndrome is a complex and controversial issue, but treatment can be one of 3 lines: medical therapy, endovascular treatment, and surgical intervention. The endovascular line was first introduced in 1993 and has been popular over other lines of treatment methods. This retrospective study was conducted in a tertiary university hospital over 24 months, from March 2019 to March 2021. Forty patients with PGS were managed by left ovarian vein TCFS. The Institutional Review Board waived the need for ethics approval or informed consent to use anonymized and retrospectively analyzed data. The mean age of enrolled women was 33.80 ± 6.54 years, ranging between 20 and 45 years. Trans-catheter ethanolamine foam embolization is an effective and safe method to treat pelvic and atypical lower limb varices.

Predictors of Carotid Artery Stenting-Induced Hemodynamic Instability.

BACKGROUND: To address the predictors of hemodynamic instability (HI) related to carotid artery stenting (CAS) and evaluate the association between HI and periprocedural adverse outcomes. METHODS: This study comprised all consecutive patients who underwent CAS for atherosclerotic carotid artery stenosis from March 2014 to May 2018. A standardized dose of atropine (0.4 mg) was given prior to stent deployment. Changes in heart rate, blood pressure, and neurological status were monitored and recorded. Potential predictors of HI were tested in multivariate analysis using binary logistic regression model. RESULTS: A total of 728 patients were enrolled. Two hundred twenty seven patients (31.2%) developed periprocedural HI. The presence of hypertension (OR, 2.037; 95% CI, 1.292-3.211; P = 0.0022), symptomatic carotid lesions (OR, 1.704; 95% CI, 1.057-2.747; P = 0.0287), right sided lesions (OR, 3.090; 95% CI, 1.934-4.935; P ≤ 0.0001), hyperechoic/calcified plaques (OR, 2.195; 95% CI, 1.458-3.304; p P = 0.0002), and longer lesions (OR, 1.043; 95% CI, 1.012-1.076; P = 0.0072) were significant predictable factors for the occurrence of HI. On the other hand, smoking was significantly associated with a 48.1% decrease in risk of development of HI (OR, 0.519; 95% CI, 0.358-0.754; P = 0.0006). There were no statistically significant differences in periprocedural morbidity or mortality between patients with and without HI. CONCLUSION: HI occurs in a considerable percentage of patients undergoing CAS. Hypertension, right sided, symptomatic carotid lesions, calcified plaques, and longer lesions were shown to be independent risk factors for the development of periprocedural HI. Conversely, smoking demonstrated a protective effect. HI did not appear to predispose to periprocedural adverse events.

Risk assessment of desert pollution on composite high voltage insulators.

Transmission lines located in the desert are subjected to desert climate, one of whose features is sandstorms. With long accumulation of sand and with the advent of moisture from rain, ambient humidity and dew, a conductive layer forms and the subsequent leakage current may lead to surface discharge, which may shorten the insulator life or lead to flashover thus interrupting the power supply. Strategically erected power lines in the Egyptian Sinai desert are typically subject to such a risk, where sandstorms are known to be common especially in the spring. In view of the very high cost of insulator cleaning operation, composite (silicon rubber) insulators are nominated to replace ceramic insulators on transmission lines in Sinai. This paper examines the flow of leakage current on sand-polluted composite insulators, which in turn enables a risk assessment of insulator failure. The study uses realistic data compiled and reported in an earlier research project about Sinai, which primarily included grain sizes of polluting sand as well as their salinity content. The paper also uses as a case study an ABB-designed composite insulator. A three-dimensional finite element technique is used to simulate the insulator and seek the potential and electric field distribution as well as the resulting leakage current flow on its polluted surface. A novel method is used to derive the probabilistic features of the insulator's leakage current, which in turn enables a risk assessment of insulator failure. This study is expected to help in critically assessing - and thus justifying - the use of this type of insulators in Sinai and similar critical areas.