COVID-19-related Peripheral Arterial Thrombosis Treated in a Large Health Maintenance Organization.

BACKGROUND: COVID-19 was initially identified as an acute respiratory disease, but it was quickly recognized that multiple organ systems could be affected. Venous thrombosis and pulmonary embolism have been well reported. However, there is a paucity of data on COVID-19-related arterial thrombosis. We examined the incidence, characteristics, treatment, and outcome in patients with acute COVID-19-related arterial thrombosis in a large health maintenance organization (HMO). METHODS: A retrospective multicenter case review was performed from March 2020 to March 2021. Cases were identified through a questionnaire sent to vascular surgeons. Patient characteristics, imaging, treatment, and outcome were reviewed. Successful revascularization was defined as restoration of blood flow with viability of the end organ and absence of death within 30 days. Limb salvage was defined as prevention of major amputation (transtibial or transfemoral) and absence of death in 30 days. RESULTS: There were 37,845 patients admitted with COVID-19 complications during this time. Among this group, 26 patients (0.07%) had COVID-19-related arterial thrombosis. The mean age was 61.7 years (range, 33-82 years) with 20 men (77%) and 6 women (23%). Ethnic minorities comprised 25 of 26 cases (96%). Peripheral arterial disease (PAD) was present in 4 of 26 (15%), active smoking in 1 of 26 (3.8%), and diabetes in 19 of 26 (73%) cases. Most patients developed acute arterial ischemia in the outpatient setting, 20 of 26 (77%). Of the outpatients, 6 of 20 (30%) had asymptomatic COVID-19 and 14 of 20 (70%) had only mild upper respiratory symptoms. Distribution of ischemia was as follows: 23 patients had at least one lower extremity ischemia, one patient had cerebral and lower extremity, one had mesenteric and lower extremity, and one had upper extremity ischemia. Revascularization was attempted in 21 patients, of which 12 of 21 (57%) were successful. Limb salvage was successful in 13 of 26 (50%) patients. The overall mortality was 31% (8/26). CONCLUSIONS: Our experience in a large HMO revealed that the incidence of COVID-19-related arterial thrombosis was low. The actual incidence is likely to be higher since our method of case collection was incomplete. The majority of arterial thrombosis occurred in the outpatient setting in patients with asymptomatic or mild/moderate COVID-19 respiratory disease. Acute ischemia was the inciting factor for hospitalization in these cases. Acute lower extremity ischemia was the most common presentation, and limb salvage rate was lower than that expected when compared to ischemia related to PAD. Arterial thrombosis associated with COVID-19 portends a significantly higher mortality. Education of primary care providers is paramount to prevent delayed diagnosis as most patients initially developed ischemia in the outpatient setting and did not have a high cardiovascular risk profile.

[Chronic leg ulcers in older patients]. / Ulcus cruris beim alten Patienten.

Chronic ulcers of the lower extremities are one of the most common medical problems encountered in western societies. The prevalence of leg ulcers is estimated to be 0.5-1.0% of the German population and is clearly associated with age. Therefore, in an aging society chronic leg ulcers are an important health issue with respect to increased morbidity and healthcare costs. The most frequent causes of leg ulcers are chronic venous insufficiency, peripheral arterial occlusive disease and diabetes mellitus. Efficient treatment necessitates an exact diagnosis and a close interdisciplinary collaboration. Affected patients often require instructions regarding self-help and support for competent nursing and prophylaxis. Therapeutic strategies, especially in the geriatric setting, aim to maintain the quality of life through preservation of patient mobility and autonomy.

[Cost and cost-effectiveness in the treatment of peripheral arterial occlusion disease - what is proven?]. / Kosten und Kosteneffizienz bei der Behandlung der peripheren arteriellen Verschlusskrankheit - was ist gesichert?

BACKGROUND: This overview comments on the health-care relevance of peripheral arterial occlusive disease (PAOD) in patients with intermittent claudication (IC) and critical limb ischaemia (CLI). We evaluated different treatment modalities in terms of cost-effectiveness. METHOD: For the literature review, the Medline database (PubMed) was searched under the key words "critical limb ischemia AND cost", "critical limb ischemia AND economy", "peripheral arterial disease AND cost", "peripheral arterial disease AND economy". RESULTS: In the years 2005 to 2009, the hospitalisations of patients with PAOD rose disproportionately in Germany by 20 %, to 483,961 hospital admissions. By comparison, hospital admissions altogether increased by only 8 %. The average in-patient costs were estimated to be approximately € 5000 per PAOD-patient - a rather conservative estimate. For the patient with IC the economic data position is clear, supervised exercise training is by far the most cost-effective treatment option, followed by percutaneous transluminal angioplasty (PTA) and finally the peripheral bypass. In accordance with the guidelines of the UK, the latter is therefore indicated only if PTA fails or is technically not possible. In patients with CLI, the situation is not obvious. Indeed, a short-term economic advantage can be calculated for the PTA, the long-term comparison of both methods, however, is impossible due to insufficient data. In addition, the risk factors for the patient have to be included in the calculation. This was indeed demonstrated in the short-term, but could not be analysed in the long-term follow-up. CONCLUSION: The issue of greater cost-effectiveness of open or endovascular treatment in patients with CLI is uncertain, the studies and patient populations are too heterogeneous. Further studies are urgently needed to structure the sequence of the various treatment options in guidelines and clinical pathways.

Clinical and epidemiological assessment concerning hybrid revascularization techniques in the treatment of multilevel arterial occlusive disease.

UNLABELLED: Aim of the study was to report a novel hybrid technique for multilevel arterial lesions of the lower extremities and to evaluate the clinical outcomes. In patients with multilevel arterial disease, the combined (hybrid) treatment, consisting of endovascular intervention and classical surgical intervention on the same vascular axis seems to be the most indicated treatment in order to obtain an adequate inflow and outflow. MATERIAL AND METHODS: We have performed a non-randomized study during a 44-month period (January 2010 - September 2013) in a number of 94 patients treated by hybrid revascularization techniques. All the patients included in the study have been post-surgically surveyed at well established intervals (1, 3, 6, 9, 12, 24 and 36 months) by: clinical examination, laboratory tests, Duplex ultrasound, and, as needed, CT or MR Angiography. RESULTS: The 6 months primary patency in each studied group (corresponding to the years of 2010, 2011 and 2012) was 58.69%, 68.42%, and 62.06%, respectively; the 12 months primary patency was 45.65%, 57.89%, and 34.48%, respectively. Clinical improvement has been noticed in 83 patients (88.29%). There have been registered 19 amputations (20.21% of the cases): 11 majors (thigh and below the knee), representing 11.7% of the total number of cases and 8 minors (toe or transmetatarsal), representing 8.51% of the total number of cases. The amputation-free survival period ranged between 7 days and 24 months, with an average of 7.66 months. CONCLUSIONS: The hybrid techniques are a feasible option for the multilevel arterial disease, with favorable patency and limb salvage rates.

Radial artery spasm during transradial cardiac catheterization and percutaneous coronary intervention: incidence, predisposing factors, prevention, and management.

Transradial cardiac catheterization and percutaneous coronary intervention are increasingly being performed worldwide in elective and emergency procedures, with many centers adopting the transradial route as their first choice of arterial access. One of the most common complications encountered during transradial procedures is radial artery spasm. This article reviews the current literature on the incidence, predisposing factors, preventive, and treatment measures for radial artery spasm.

Ischemic complications after pancreaticoduodenectomy: incidence, prevention, and management.

OBJECTIVE: To assess prevalence, prevention, and management strategy of visceral ischemic complications after pancreaticoduodenectomy (PD). BACKGROUND: Ischemic complications after PD resulting from preexisting celiac axis (CA), superior mesenteric artery (SMA), stenosis, or intraoperative arterial trauma appear as an underestimated cause of death. Their prevention and adequate management are challenging. METHODS: From 1995 to 2006, 545 PD were performed in our institution. All patients were evaluated by thin section multidetector computed tomography (CT) with arterial reconstruction to detect and class SMA or CA stenosis. Hemodynamical significance of stenosis was assessed preoperatively by arteriography for atherosclerotic stenosis and intraoperatively by gastroduodenal artery clamping test for CA compression by median arcuate ligament. Significant atherosclerotic stenosis was stented or bypassed, whereas CA compression was treated by median arcuate ligament division during PD. Multidetector-CT accuracy to detect arterial stenosis, results of revascularization procedures, and both prevalence and prognosis of ischemic complications after PD were analyzed. RESULTS: Among 62 (11%) stenoses detected by multidetector-CT, 27 (5%) were hemodynamically significant, including 23 CA compressions by median arcuate ligament, 2 CA, and 2 SMA atherosclerotic stenoses, respectively. All atherosclerotic stenoses were successfully treated by preoperative stenting (n = 3) or bypass (n = 1). Among the 23 cases who underwent median arcuate ligament division, 3 (13%) failed due to 1 CA injury and 2 misdiagnosed intrinsic CA stenoses. Overall, 6 patients developed ischemic complications, due to intraoperative hepatic artery injury (n = 4), unrecognized SMA atherosclerotic stenosis (n = 1), or CA fibromuscular dysplasia (n = 1). Five (83%) of them died, representing 36% of the 14 deaths of the whole series (overall mortality = 2.6%). Overall, CT detected significant arterial stenosis with a 96% sensitivity and determined etiology of CA stenosis with a 92% accuracy. CONCLUSIONS: Ischemic complications are an underestimated cause of death after PD and are due to preexisting stenoses of CA and SMA, or intraoperative hepatic artery injury. Preexisting arterial stenoses are detected by routine multidetector CT. Preoperative endovascular stenting for intrinsic stenosis, division of median arcuate ligament for extrinsic compression, and meticulous dissection of the hepatic artery can contribute to minimize ischemic complications.

Assessment of the abdominal aorta and its visceral branches by contrast-enhanced dynamic volumetric hepatic parallel magnetic resonance imaging: feasibility, reliability and accuracy.

The purpose of this study was to evaluate a new three-dimensional gradient-echo (GRE) MR sequence performed with a parallel acquisition technique to shorten breath-hold times (parallel GRE MRI) in the detection of arterial variants and stenosis of the abdominal aorta and its visceral branches. A total of 102 patients underwent dynamic parallel GRE MRI, timed to the arterial phase by a test bolus (mean breath-hold time, 17 s). For both quantitative and qualitative analysis, the abdominal aorta and its visceral branches were divided into 13 arterial segments. In a subanalysis of 55/102 patients, the accuracy of parallel GRE MRI compared to MDCT in the detection arterial variants and stenosis was calculated for two independent readers. Mean SNRs and CNRs were 47.2 and 35.6, respectively. Image quality was rated good or excellent in 1,234/1,326 segments (93%). Hepatic and renal arterial variants were identified with an accuracy of 93 and 95%, respectively (reader 1) and 98 and 100%, respectively (reader 2). Both readers detected arterial stenosis with an accuracy of 98%. Interobserver agreement was good to excellent for the detection of hepatic (kappa=0.69) and renal (kappa=0.92) variants and for the diagnosis of stenosis (kappa=0.96). Dynamic three-dimensional parallel GRE MRI is feasible and allows a reliable and accurate diagnosis of arterial variants and stenosis of the abdominal aorta and its visceral branches in a short breath-hold-time.

[Markers predicting progression of disease in PAD: Which of them are both relevant to clinical practice and economically justifiable?]. / Prädiktive Marker der Krankheitsprogression bei pAVK. Welche sind praxisrelevant und ökonomisch vertretbar?

The high cardiovascular morbidity and mortality on peripheral arterial disease (PAD) are attributable to the pronounced tendency to generalization of the atherosclerotic process, the systemic progression of atherosclerosis. The crucial objective in management of a PAD consists in preventing systemic progression. The prognosis can be improved by early diagnosis and early prediction of individual risk with subsequent risk-adapted prevention and causal therapy. Early diagnosis and risk prediction are measures that are already part of the repertory of the general practitioner. Practicable and economically justifiable parameters that nevertheless have a high predictive value are therefore required to stratify individual risk. The vascular indicators ankle-arm index and the localization of the PAD as well as the classical cardiovascular risk factors including homocysteine are suitable. Weighting of these parameters in a multivariable risk score enable the population with the highest risk of early generalization of atherosclerosis to be identified in PAD.

Get the LEAD out: noninvasive assessment for lower extremity arterial disease using ankle brachial index and toe brachial index measurements.

Lower extremity arterial disease affects approximately one third of individuals 66 years of age and older and has a high risk for nonhealing wounds, infection, and limb loss. Much wound care is given by or under the direction of nurses. Therefore, the assessment and management of these patients presents many opportunities and challenges. Assessment is the cornerstone of effective care, but traditional methods of lower extremity arterial assessment, such as pulse palpation and pain history, are insufficient to determine the presence and extent of ischemia. Recently published national guidelines for assessment and management of patients with lower extremity wounds have recommended using noninvasive tests such as the ankle brachial index and toe brachial index to rule out lower extremity arterial disease, which complicates wound healing. However, the ankle brachial index can be falsely elevated in patients with diabetes and renal failure because of calcification of the arteries, which causes them to be incompressible. In these situations, it has been advised to obtain a toe pressure or toe brachial index because digital arteries are usually less affected by calcification. There is a paucity of data about the knowledge of principles and performance of the ankle brachial index/toe brachial index by nurses, particularly in the United States, using pocket-sized portable Doppler equipment. Therefore, the purpose of this article is to provide an overview and synthesis of relevant studies and published expert opinion regarding noninvasive arterial assessment using ankle brachial and toe brachial indexes as a basis for developing protocols for performing the tests and identifying gaps in research where further investigation is needed.

Treatment costs and quality of life of patients with peripheral arterial occlusive disease--the German perspective.

BACKGROUND: To objectify the debate about the restricted resources of the health system, examinations about the treatment costs and quality of life implications of different illnesses are necessary. The aims of the examination were the quantification of costs that are caused by a patient with PAD per year and the determination of the quality of life. PATIENTS AND METHODS: 280 patients (mean 66.6 years) in Fontaine stages II to IV were included in the study to determine their treatment costs for the year 2001 retrospectively from patient records. Health-related quality of life was recorded through the standardized questionnaires PAVK-86, SF-36 and EQ-5D. RESULTS: A patient with PAD in stage Ila costs on average 1792.45 Euros, in stage IIb 2551.28 Euros, in stage III 4356.48 Euros and in stage IV 6225.89 Euros. The costs of the in-hospital treatment dominated the total result on average with 44.4% of the direct costs. Further cost factors were the drugs with 33.4%, the out-patient medical treatment with 9.9%, the expenditures for care with 6.7%, rehabilitation with 3.6% and adjuvants with a share of 1.9%. The indirect costs played a subordinate role with 9.67% of the total costs. The quality of life was clearly restricted in all stages of the PAD. The quality of life especially was strongly decreased from the Fontaine stage IIb on. The problems were mainly in the areas of the physicalfunctions and pain. CONCLUSION: The study showed that the treatment of patients with PAD is very cost-intensive and that patients have to suffer from a considerable loss of quality of life.

Balloon angioplasty for arteriovenous graft stenosis.

PURPOSE: To retrospectively review the long-term outcome as well as the cost effectiveness of thrombolytic therapy and balloon angioplasty (TBA) versus surgical thrombectomy and balloon angioplasty (SBA) in the treatment of prosthetic dialysis access grafts. METHODS: Between February 1996 and February 1999, 63 hemodialysis patients (35 women; mean age 62.2 years) were treated for 105 thromboses in 6-mm polytetrafluoroethylene straight or loop bridge arteriovenous grafts. Choice of treatment was at the discretion of the surgeon or interventional radiologist: either Fogarty balloon thrombectomy followed by balloon dilation of the venous anastomotic stenosis or urokinase thrombolysis followed by angioplasty. RESULTS: Forty-eight SBAs and 55 TBAs were performed in 63 patients without complications. The primary patency rates in the entire cohort were 34%, 29%, and 17% at 1, 2, and 3 months, respectively. Primary patency after TBA was 29%, 18%, and 11%, and that for SBA, 45%, 45%, and 33% over the same time intervals. The mean graft survival was 10 days for TBA versus 31 days for SBA. Repeat angioplasty performed in 23 grafts produced secondary patency rates of 52% at 1 month, 34% at 3 months, and 5% at 5 months. The Medicare reimbursement for both treatments was identical ($1638 for TBA and $1670 for SBA). CONCLUSIONS: The poor patency rate and high cost of TBA and SBA suggests that these procedures should not be routinely used for salvage of thrombosed arteriovenous grafts with outflow stenosis. Patch angioplasty or creation of simultaneous temporary and new permanent accesses may be a more cost-effective approach in these patients.

The role of comorbidity in the assessment of intermittent claudication in older adults.

The prevalence of intermittent claudication (IC) in older adults by questionnaire is less than 5% while the prevalence of peripheral arterial disease (PAD) by non-invasive testing is 2-4-fold higher. Comorbid conditions may result in under-reporting intermittent claudication (IC) as assessed by the Rose Questionnaire. We examined characteristics of those who report leg pain in relationship to other comorbid conditions and disability in 5888 participants of the Cardiovascular Health Study (CHS). Older adults with exertional leg pain, not meeting criteria for IC, had a higher prevalence of PAD on non-invasive testing with the ankle-arm index than those without pain, as well as a higher prevalence of arthritis. The pattern of responses suggested that pain for both conditions was reported together. The Rose Questionnaire for IC is specific for PAD, but a negative questionnaire does not indicate a lack of symptoms, rather the presence of PAD along with other conditions that can cause pain.

[Percutaneous treatment of peripheral obstructive arteriopathy: the reasons for a choice]. / Il trattamento percutaneo delle arteriopatie ostruttive periferiche: i perché di una scelta.

Progressive aging of the Italian population is a relevant fact and this increases the occurrence of peripheral vascular disease in this subset of the population. At the same time, due to the national demographic decline, more and more aged people are going to live on their own. In this category the problem of self-caring is becoming highly relevant considering that only 12-13% of patients who had a limb amputation will walk with an artificial leg. This implies relevant social costs which are somewhat hidden because of their distribution in society (hospital, home care, individuals). Undoubtedly, there will be a dramatic reduction in the quality of life for these people. New technological progress and the development of new treatment modalities in the last decade have had a profound impact on the care of these patients. The role of peripheral vessel arteriography as a gold standard for the final evaluation of the disease and for the possibility of endovascular treatment has been widely accepted. Percutaneous transluminal intervention has proven to be more efficient economically with less morbidity and mortality than traditional vascular surgery, mainly in the limb salvage subgroup of patients. Health organization authorities should take these changes into account and modify their attitude towards the treatment of this pathology in order to provide better care for patients and to better allocate the economical resources of the National Health System.

Impact of race on the treatment for peripheral arterial occlusive disease.

PURPOSE: The purpose of this study was to determine the impact of race on the treatment of peripheral artery occlusive disease (PAOD) and to examine the role of access to care and disease distribution on the observed racial disparity. METHODS: The study was performed as a retrospective analysis of hospital discharge abstracts from 1992 to 1995 in 202 non-federal, acute-care hospitals in the state of Florida. The subjects were patients older than 44 years of age who underwent major lower extremity amputation or revascularization (bypass grafting or angioplasty) for PAOD. The main outcome measures were incidence of intervention, incidence per demographic group, multivariate predictors of amputation versus revascularization, multivariate predictors of amputation versus revascularization among those patients with access to sophisticated care (hospital with arteriographic capabilities), and multivariate predictors of surgical bypass graft type (aortoiliac vs infrainguinal). RESULTS: A total of 51,819 procedures (9.1 per 10,000 population) were performed for PAOD during the study period and included 15,579 major lower extremity amputations (30.1%) and 36,240 revascularizations (69.9%). Although the incidence of a procedure for PAOD was comparable between African Americans and whites (9.0 vs 9.6 per 10, 000 demographic group), the incidence of amputation (5.0 vs 2.5 per 10,000 demographic group) was higher and the incidence of revascularization (4.0 vs 7.1 per 10,000 demographic group) was lower among African Americans. Furthermore, multivariate analysis results showed that African Americans (odds ratio, 3.79; 95% confidence interval [CI], 3.34 to 4.30) were significantly more likely than whites to undergo amputation as opposed to revascularization. The secondary multivariate analyses results revealed that African Americans (odds ratio, 2.29; 95% CI, 1.58 to 3. 33) were more likely to undergo amputation among those patients (n = 9193) who underwent arteriography during the procedural admission and to undergo infrainguinal bypass grafting (odds ratio, 2.00; 95% CI, 1.48 to 2.71) among those patients (n = 27,796) who underwent surgical bypass grafting. CONCLUSION: There is a marked racial disparity in the treatment of patients with PAOD that may be caused in part by differences in the severity of disease or disease distribution.