Pharmacomechanical thrombectomy with Angiojet in acute arterial occlusions: A prospective study among the results and outcomes.

OBJECTIVE: The main objective of this present paper was to evaluate the results and outcomes of patients with acute limb ischemia (ALI) submitted to pharmacomechanical thrombectomy (PMT) endovascular surgery with Angiojet, regarding the number of cycles/pumps. METHODS: Prospective, consecutive cohort study of ALI patients submitted to PMT endovascular intervention subdivided into two groups according to the number of cycles in the Angiojet technique: Group 1 higher than 150 cycles/second and Group 2 lesser than 150 cycles/second (cycles/s). RESULTS: Overall, 92 patients with ALI submitted to PMT were evaluated. Two groups of patients were identified: Group 1 higher than 150 cycles/s with 60 patients and Group 2 lesser than 150 cycles/s with 32 patients. The overall mortality rate (OMR) was 15.1% (13 patients) in total cohort within the first 30 days. Group 1 had a higher OMR than Group 2 (16.1% vs 9.3%, p = 0.007). There were 4 cases of hematuria (4.3%), all of them in Group 1. We have performed a Kaplan-Meier regarding limb salvage rates: Group 1 had 85% and Group 2 had 95.7% at 1057 days. P = 0.081. Among the factors evaluated, the following were related to overall mortality rate: PMT with higher >150 cycles/s (HR = 7.17, p = 0.007, CI: 1.38-8.89), COVID-19 infection (HR = 2.75, p = 0.010, CI = 1.73-5.97), and post-operative acute kidney injury (HR = 2.97, p < 0.001, CI = 1.32-8.13). Among the factors evaluated, the following was related to limb loss: post-operative acute kidney injury (HR = 4.41, p = 0.036, CI: 1.771-7.132), probably because patients experiencing limb loss have a higher incidence of acute renal insufficiency due to higher circulating myoglobin higher hemolysis from the increased Angiojet cycles inducing rhabdomyolysis. CONCLUSION: PMT with Angiojet is a safe and effective therapy in patients with ALI. However, patients receiving greater than 150 cycles/s were noted to have higher rates of acute kidney injury and mortality. This is likely reflective of increased thrombus burden and higher rates of hemolysis. Acute kidney injury, greater than 150 cycles/s, and COVID-19 infection were the variables with the strongest association to perioperative mortality.

The Importance of the Circle of Willis in Carotid Interventions Outcomes: A Real-Life Study.

BACKGROUND: The main objective of this study is to evaluate and compare the outcomes regarding operative mortality rate, ipsilateral stroke, and overall survival rate among patients with internal carotid artery stenosis submitted to carotid endarterectomy (CEA) or stenting regarding the completeness of circle of Willis (CoW). METHODS: Prospective, consecutive cohort study of patients submitted to carotid interventions (CEA and carotid stenting: CAS) for internal carotid artery stenosis diagnosis evaluated according complete or incomplete CoW. The patients were divided into 2 groups: group I, the patients with complete CoW and group II, the patients with incomplete CoW, with the disruption of anterior and/or ipsilateral posterior circulation, regarding the ipsilateral significant carotid stenosis. RESULTS: Overall, 98 patients submitted to carotid intervention were evaluated. Two groups of patients were identified: group CoW complete with 54 patients and group CoW incomplete with 44 patients. Regarding the type of intervention, the prevalence of CAS in CoW complete group and CoW incomplete group were statistically similar (54.1% vs. 55.1%, P = 0.22). Notwithstanding, CEA was also statistically similar in CoW incomplete group and CoW complete group (44.2% vs. 45.9%, P = 0.22). The perioperative mortality rate was 2% in total cohort (2 patients), with no differences among CoW complete and incomplete groups (3.7% vs. 0%, P = 0.50, respectively). Furthermore, the incidence of postoperative stroke was 3.1% (asymptomatic 2%, symptomatic 1.1%), with no differences among CoW complete and incomplete groups (3.7% vs. 2.3%, P = 0.68, respectively). A univariate and multivariate linear regression showed that among the factors evaluated, only chronic kidney failure was related with hazard ratio = 1.89, P = 0.003, confidence interval 1.058-2.850. CONCLUSIONS: The completeness of the CoW, independently of the type of carotid intervention (CEA and CAS), did not interfere in the results regarding postoperative outcomes for stroke and death. Chronic kidney disease was associated to increased risk of perioperative stroke.

The value of Wound, Ischemia and foot Infection classification in patients undergoing endovascular therapy.

OBJECTIVE: This study aimed to evaluate the correlation between the Society for Vascular Surgery (SVS) Wound, Ischemia and foot infection (WIfI) classification system and clinical outcomes for 1-year limb amputation-free survival (AFS), freedom from reintervention, and wound healing rate in a cohort of patients affected by chronic limb-threatening ischemia treated exclusively by endovascular procedures. METHODS: We analyzed a prospective, consecutive cohort of 203 patients (203 limbs) who underwent infrainguinal endovascular revascularization at a single center between March 2018 and January 2021. These patients were stratified into clinical stages 1 to 4 based on the SVS WIfI classification and categorized into two groups: WIfI 1 to 3 (n = 101 limbs) and WIfI 4 (n = 102 limbs). The SVS objective performance goals of 1-year limb AFS, freedom from reintervention, and wound healing were compared between the groups and assessed using the Kaplan-Meier method. Angiographic lesion characteristics and angioplasty details were compared. RESULTS: The average age was 72.4 years (44.3% male, 85.2% had hypertension, 80.3% had diabetes, and 87.7% had tissue loss). There were statistical differences between the groups in 1-year limb AFS Kaplan-Meier rate between WIfI clinical stages 1 to 3 group and WIfI clinical stage 4 group (82% vs 66%, respectively; P < .001), but there was no statistical difference in freedom from reintervention and wound healing rates between the groups (70% vs 64% [P = .62] and 74% vs 79% [P = .90], respectively). Owing to angiographic lesion characteristics, femoropopliteal and infrapopliteal segment distributions were similar between the groups, but there was a statistical difference in target lesion location to tibial vessels (55.4% vs 71.6%, respectively; P = .025). CONCLUSIONS: In this cohort of patients with chronic limb-threatening ischemia, SVS WIfI clinical stage 4 had worse results in the 1-year limb AFS rate, but there was no statistical difference in freedom from reintervention and wound healing rates between the groups.

Efficacy and safety of iliofemoral bypass using arm veins as an alternative conduit for chronic limb-threatening ischemia.

OBJECTIVE: The use of basilic vein in iliofemoral revascularizations was previously described in the literature as an autologous option for the treatment of vascular prosthesis infection and as a primary conduit in patients at high risk of infectious surgical complications. However, the publications available include several different indications and are limited to case reports. Therefore, the aim of this study was to evaluate the outcomes of the use of arm veins as a safe and effective autologous alternative for iliofemoral reconstruction in patients with chronic limb-threatening ischemia (CLTI) and at high risk of prosthesis infection. METHODS: We performed a multicenter, retrospective cohort study with 53 consecutive iliofemoral bypasses using arm veins as an alternative conduit. The procedures were performed between November 2013 and November 2021, exclusively for patients with CLTI classified as TASC aortoiliac C or D with increased risk of postoperative surgical infection. Demographic, clinical variables, and outcomes were collected from a prospective database. Main endpoints were amputation-free survival (AFS) and major adverse cardiovascular events. Secondary endpoints included primary and secondary patencies and overall survival. Cox regression analysis was used to identify the predictors of AFS. Postoperative surgical complications and 30-day mortality were also assessed. RESULTS: The mean age was 64.2 ± 8.4 years, with a predominance of male gender. The median follow-up period was 615 days. All patients had CLTI, with a predominance of tissue loss (n = 51; 96.2%) and a median ankle-brachial index of 0.28. The basilic vein was utilized in most procedures (69.8%). Thirty-day major adverse cardiovascular events occurred in five cases (9.4%), and the 30-day mortality rate was 3.8%. The AFS, primary patency, secondary patency, and overall survival in 720 days were 71%, 72%, 89%, and 75%, respectively. Cox regression analysis revealed no association between the variables analyzed for AFS. There was no graft late infection nor pseudoaneurysmal degeneration. CONCLUSIONS: Iliofemoral bypass using arm veins as an autologous conduit proved to be an effective and safe procedure with low incidence of postoperative cardiovascular complications and high rates of AFS in patients with CLTI. Also, this suggests that arm veins can be an interesting and suitable autologous alternative conduit for iliofemoral reconstructions, especially in cases in which a prosthesis should be avoided or when it is not available.

A Comparative Analysis and Results of Carotid Interventions Based on Duplex Ultrasound as a Single Exam Versus Multiple Diagnose Exams.

BACKGROUND: To determine the results, safety, and clinical outcomes of carotid interventions performed with duplex ultrasound (DUS) as a single preoperative image for internal carotid artery (ICA) assessment, compared to computed tomography angiography (CTA) and magnetic resonance angiography (MRA). METHODS: Prospective, consecutive cohort study of 2 groups of patients submitted to carotid interventions, 1 group of patients with DUS as a sole exam (group DUS) compared to patients with DUS plus CTA or MRA for ICA stenosis diagnosis (group CTA/MRA) regarding clinical outcomes such as major stroke, minor stroke, transient ischemic attack and perioperative mortality. RESULTS: Two groups of patients were identified: group DUS with 47 patients and group CTA/MRA plus DUS with 68 patients. The mean age of the patients was 71.67 years in total cohort, and most of them were male (66.1%). Group DUS had higher prevalence of male, dyslipidemia, ischemic heart disease, peripheral artery disease and chronic kidney disease than group CTA/MRA (83% vs. 54.4%, P = 0.001; 93.6% vs. 51.5%, P < 0.001; 36.2% vs. 16.2%, P = 0.009; 29.8% vs. 13.2%, P = 0.019; 14.9% vs. 5.9%, P = 0.007, respectively). We have performed a Kaplan-Meier regarding survival rates: Group DUS had 93.5%% and Group CTA/MRA had 90.3%% at 720 days. P = 0.15, standard error < 10 at 720 days. a Kaplan-Meier analysis regarding primary patency rates showed Group DUS with 92.7% and Group CTA/MRA with 94.7% at 720 days. P = 0.78, standard error < 10 at 720 days. Furthermore, the incidence of postoperative stroke was 2.6% (asymptomatic 1.7%, symptomatic 2.9%), with no differences among DUS and CTA/MRA groups (2.1% vs. 2.9%, P = 0.78, respectively). CONCLUSIONS: Independently of the type of carotid intervention (carotid endarterectomy and carotid stenting (CAS)), DUS as an only preoperative carotid image has similar results regarding postoperative outcomes when compared to CTA/MRA for preoperative carotid evaluation.

Efficacy and safety of iliofemoral bypass using arm veins as an alternative conduit for chronic limb-threatening ischemia

OBJECTIVE: The use of basilic vein in iliofemoral revascularizations was previously described in the literature as an autologous option for the treatment of vascular prosthesis infection and as a primary conduit in patients at high risk of infectious surgical complications. However, the publications available include several different indications and are limited to case reports. Therefore, the aim of this study was to evaluate the outcomes of the use of arm veins as a safe and effective autologous alternative for iliofemoral reconstruction in patients with chronic limb-threatening ischemia (CLTI) and at high risk of prosthesis infection. METHODS: We performed a multicenter, retrospective cohort study with 53 consecutive iliofemoral bypasses using arm veins as an alternative conduit. The procedures were performed between November 2013 and November 2021, exclusively for patients with CLTI classified as TASC aortoiliac C or D with increased risk of postoperative surgical infection. Demographic, clinical variables, and outcomes were collected from a prospective database. Main endpoints were amputation-free survival (AFS) and major adverse cardiovascular events. Secondary endpoints included primary and secondary patencies and overall survival. Cox regression analysis was used to identify the predictors of AFS. Postoperative surgical complications and 30-day mortality were also assessed. RESULTS: The mean age was 64.2 ± 8.4 years, with a predominance of male gender. The median follow-up period was 615 days. All patients had CLTI, with a predominance of tissue loss (n = 51; 96.2%) and a median ankle-brachial index of 0.28. The basilic vein was utilized in most procedures (69.8%). Thirty-day major adverse cardiovascular events occurred in five cases (9.4%), and the 30-day mortality rate was 3.8%. The AFS, primary patency, secondary patency, and overall survival in 720 days were 71%, 72%, 89%, and 75%, respectively. Cox regression analysis revealed no association between the variables analyzed for AFS. There was no graft late infection nor pseudoaneurysmal degeneration. CONCLUSIONS: Iliofemoral bypass using arm veins as an autologous conduit proved to be an effective and safe procedure with low incidence of postoperative cardiovascular complications and high rates of AFS in patients with CLTI. Also, this suggests that arm veins can be an interesting and suitable autologous alternative conduit for iliofemoral reconstructions, especially in cases in which a prosthesis should be avoided or when it is not available.

The Importance of the Hypogastric Artery Preservation during Treatment for Aortoiliac Aneurysms: A Prospective Single-Center Study.

BACKGROUND: To determine the importance of the hypogastric artery for the outcomes of survival, endoleaks, reinterventions, buttock claudication (BC), and perioperative mortality rate (PMR) in patients with aortoiliac aneurysms (AIA) receiving endovascular or open surgical (OS) repair. METHODS: This was a prospective consecutive cohort study of patients with AIA who underwent endovascular treatment or OS repair during the period of 2010-2021. Endovascular repair was performed with use of aortoiliac endoprosthesis associated with internal iliac artery (IIA) coil embolization and/or with iliac branch endoprosthesis (IBE) in order to preserve the IIA. The AIA OS repairs were performed with the artery ligation in order to exclude the IIA, or in some cases, the exclusion of the IIA was performed with an endosuture in the proximal stump of the artery. Three groups were identified in the postprocedural period: group 0 (no hypogastric arteries (HAs) preserved), group 1 (1 hypogastric artery preserved), and group 2 (2 hypogastric arteries preserved). RESULTS: A total of 91 patients were submitted to OS or endovascular surgery. Regarding the HA patency, there were 17 patients in group 0, 45 patients in group 1, and 29 patients in group 2. There were 17 cases of bowel ischemia (BI) (94.1% in group 0, 5.9% in group 1, and no cases in group 2, P < 0.001) most of them in group 0, with statistical significance, 12 cases of BC (91.7% in group 0, 8.3% in group 1, and no cases in group 2, P < 0.001), most of them in group 0, with statistical significance. The perioperative mortality was 14.3%, 13 patients (9 patients - 52.9% group 0, 3 patients - 6.7% group 1, and 1 patient - 3.4% group 2, P < 0.001). The linear regression analysis for survival rates showed that BI [P = 0.026 to hazard ratio (HR) = 1.69], emergency aortoiliac repair (P < 0.001, HR = 8.86), and number of HAs (P < 0.001, HR = 5.46) in postoperative were related to poorer survival rates in both univariate and multivariate analysis. The linear regression analysis showed that the number of HAs (P < 0.001, HR = 3.61) in postoperative, emergency aortoiliac repair (P = 0.002, HR 3.233), and cardiac disease (P = 0.048, HR = 3.84) were related to BI. CONCLUSIONS: In conclusion, the number of HA is crucial for adequate and safe outcomes after abdominal aortic aneurysm (AAA) repair. The main factors related to death were BI, emergency aortoiliac repair, and the number of HAs preserved. Moreover, the main factors related to BI were the number of HAs in postoperative, emergency aortoiliac repair, and cardiac disease.

Microbiology of Diabetic Foot Infections in a Tertiary Care Hospital in São Paulo, Brazil.

Diabetic foot infections (DFIs) are one of the causes of hospitalization in diabetic patients and, when this occurs, empirical antibiotic therapy is necessary. We have conducted a retrospective study of patients with DFI that required hospitalization to evaluate microbiologic profile and the susceptibility pattern of these infections. We evaluated 320 patients, of which 223 (69.7%) were male with a media age of 71 years with 276 isolates. Gram-positive bacteria were responsible for 188 (68.1%) of the isolates, while Gram-negative bacilli were responsible for 88 (31.9%). E. faecalis was the most prevalent pathogen, followed by S. aureus and coagulase negative Staphylococci. Among Gram-negative pathogens, P. aeruginosa was the most prevalent agent. Regarding the susceptibility profile, we found ampicillin-sensitive enterococci in 89% of the cases, oxacillin-sensitive S. aureus in 47%, but in coagulase-negative staphylococci, oxacillin was sensible only in 20%. The susceptibility profile of Gram-negatives was very good with 76% susceptibility of P. aeruginosa to ceftazidime and meropenem. The other prevalent Enterobacterales had great susceptibility to ceftazidime, piperacillin-tazobactam and 100% susceptibility to meropenem, with the exception of K. pneumoniae, which had 75% susceptibility to meropenem. Knowledge of microbiological profile and susceptibility patterns of patients with DFIs is useful to guide empirical therapy.

Late Outcomes of Elective Endovascular Abdominal Aortic Aneurysm Repair in a Tertiary Low-Volume Hospital in Brazil.

BACKGROUND: The aim of this study is to report early and long-term results of elective endovascular aneurysm repair (EVAR) in a tertiary low-volume hospital in Brazil. METHODS: Between October 2006 and May 2017, 120 patients underwent elective EVAR for infrarenal aortic aneurysm. The interventions were reviewed retrospectively, focusing on 30-day mortality, long-term survival, and freedom from reintervention. Late outcomes were assessed by the Kaplan-Meier method and Cox regression. RESULTS: The follow-up's median and interquartile range was 3 (1-5) years. Overall, most patients were males (75%) and the median age was 74 years. Mostly patients were at a high risk for intervention (79.1%) and the majority was classified as American Society of Anesthesiologists III (53.3%). Preoperative aneurysm diameter median was 60 mm, interquartile range was 52.7-69. As per the postoperative aneurysm sac evolution, the number of patients with a reduction, stabilization, or an increase was 93 (77.5%), 18 (15%), and 9 (7.5%), respectively. The 30-day mortality was 6.6% and no late aneurysm-related deaths were identified. The overall incidence of late endoleaks was 24.1%, with the predominance of type II (23.3%), followed by type IA (0.8 %). Secondary interventions were necessary for 9 patients (7.5%). The 6-year analyses revealed freedom from reintervention and overall survival of 87.9% and 57.7%, respectively. The Cox regression analyses identified age > 75 years as an adverse factor for overall survival (hazard ratio = 2.5; P = 0.021). CONCLUSIONS: In the present study, EVAR in a low-volume center was associated with high 30-day mortality, but satisfactory long-term results were identified.

Acute Arterial Occlusions in COVID-19 Times: A Comparison Study Among Patients with Acute Limb Ischemia With or Without COVID-19 Infection.

BACKGROUND: To determine the impact of coronavirus (COVID-19) infection in patients with acute limb ischemia (ALI), mainly the limb salvage estimates the rate and the overall survival rate. METHODS: This was a prospective, consecutive cohort study of ALI patients with or without COVID-19 infection. Two groups of patients were identified: patients with ALI and COVID-19 infection and patients with ALI and without COVID-19 infection. The comparisons among the 2 groups were performed with proper statistical analysis methods. RESULTS: Two groups of patients were identified: ALI and COVID-19 infection with 23 patients and ALI without COVID-19 infection with 49 patients. The overall mortality rate (OMR) was 20.8% (15 patients) in total cohort within the first 30 days. COVID-19 group had a higher OMR than non-COVID-19 group (30.4% vs. 16.7%, P = 0.04). The limb salvage rate at 30 days was 79.1% in total cohort; however, non-COVID-19 infection group had higher limb salvage rates than COVID-19 infection group (89.7% vs. 60.8%, P = 0.01). A univariate and multivariate logistic regression was performed to test the factors related to a major amputation rate. Among the factors evaluated, the following were related to limb loss: D-dimer > 1,000 mg/mL (hazards ratio [HR] = 3.76, P = 0.027, CI = 1.85-5.89) and COVID-19 infection (HR = 1.38, P = 0.035, CI = 1.03-4.75). Moreover, a univariate and multivariate logistic regression analysis was performed to analyze the factors related to overall mortality. Among the factors evaluated, the following were related to OMR: D-dimer > 1,000 mg/dL (HR = 2.28, P = 0.038, CI: 1.94-6.52), COVID-19 infection (HR = 1.8, P = 0.018, CI = 1.01-4.01), and pharmacomechanical thrombectomy >150 cycles (HR = 2.01, P = 0.002, CI = 1.005-6.781). CONCLUSIONS: COVID-19 has a worse prognosis among patients with ALI, with higher rates of limb loss and overall mortality relative to non-COVID patients. The main factors related to overall mortality were D-dimer > 1,000 mg/dL, COVID-19 infection, and pharmacomechanical thrombectomy >150 cycles. The factors related to limb loss were D-dimer > 1,000 mg/mL and COVID-19 infection.

The catastrophic impact of COVID-19 infection in patients with chronic limb-threatening ischemia.

BACKGROUND: To determine the impact of COVID-19 infection in patients with chronic limb-threatening ischemia, mainly the limb salvage estimates rate and the overall survival. METHODS: This was a retrospective, consecutive cohort study of chronic limb-threatening ischemia in patients with COVID-19 infection. RESULTS: Overall, 35 patients with chronic limb-threatening ischemia and COVID-19 infection were evaluated. The mean age of the patients was 72.51 years, and most of them were male (60%), with arterial hypertension (85.7%), followed by diabetes mellitus (80%) and tobacco user (71.4%). There was a higher prevalence of wound, ischemia and foot infection (WIfI) classification 4 with 58.8% and Rutherford grade 5 (74.3%). The factors related to overall mortality rate were: D-dimer >1,000 mg/dL (hazard ratio = 22.7, P < .001, confidence interval = 10.49-26.52), respiratory symptoms (hazard ratio = 16.6, P < .001, confidence interval = 9.87-20.90), chest computed tomography compromising higher than 50% of the pulmonary tract (hazard ratio = 16,0, P < .001, confidence interval = 10.41-20.55), acute kidney failure (hazard ratio = 21.58, P < .001, confidence interval = 16.5-30.5), chronic kidney disease (hazard ratio = 4.4, P = .036, confidence interval = 1.45-10.1), therapeutic anticoagulation (hazard ratio = 8.37, P = .004, confidence interval = 1.35-8.45), and WIfI classification (hazard ratio = 5.28, P = .022, confidence interval = 1.34-10.01). The following were related to limb loss: D-dimer >1,000 mg/mL (hazard ratio = 5.47, P = .02, confidence interval = 1.94-10.52), respiratory symptoms (hazard ratio = 5.42, P = .02, confidence interval = 1.87-10.90), and WIfI classification (hazard ratio = 4.44, P = .035, confidence interval = 1.34-8.01). CONCLUSION: This study concluded that COVID-19 has a catastrophic impact among patients with chronic limb-threatening ischemia. The main factors related to overall mortality were D-dimer >1,000 mg/dL, respiratory symptoms, chest computed tomography compromising higher than 50% of the pulmonary tract, acute kidney failure, chronic kidney disease, therapeutic anticoagulation, and WIfI classification. The factors related to limb loss were WIfI classification, D-dimer >1,000 mg/mL and respiratory symptoms.

Cardiovascular Risk Assessment in Women With Rheumatoid Arthritis Through Carotid and Femoral Artery Doppler Ultrasound.

OBJECTIVE: The aims of this study were to assess cardiovascular risk in patients with rheumatoid arthritis (RA) classified as low-risk by the Framingham score, before and after the multiplication by 1.5 recommended by the European League Against Rheumatism (EULAR), and to stratify them using carotid and femoral Doppler ultrasound (DUS) in order to optimize the assessment of the asymptomatic cardiovascular disease incidence. METHODS: Thirty-five female patients with RA and 35 healthy women (control group), both with low cardiovascular risk by Framingham score, were enrolled in the study (randomized). All of them underwent carotid and femoral DUS studies. RESULTS: The mean age at diagnosis was 44.57 years, the mean disease duration was 12.11 years and the mean disease activity score according to the Disease Activity Score 28 was 1.91, whereas according to the Clinical Disease Activity Index, it was 6.176. The sample was homogeneous. Within the RA group, 46% showed changes in the carotid and/or femoral DUS, compared with 14% in the control group (p = 0.004). Of the DUS with abnormalities, in the RA group, 31% of the carotid DUS and 81% of the femoral DUS (p = 0.005) showed intima-media thickness and/or atherosclerotic plaques. After EULAR 1.5 multiplication factor, 66% remained low cardiovascular risk. Of these, 35% of the patients showed changes in the carotid and/or femoral DUS, compared with 14% of the control group (p = 0.07). CONCLUSIONS: The EULAR criteria are effective at identifying patients with high cardiovascular risk. Carotid DUS and, especially, femoral DUS are tools that can be used in clinical practice as ways to detect CVD even in its asymptomatic form.

Smartphone application for wound area measurement in clinical practice.

A total of 85 consecutive patients had their wound area measured. The procedure was executed in two parts. The first was to take photographs of the wound using a smartphone and measure the area using the imitoMeasure application (imito; imito AG, Zurich, Switzerland) by two raters. The second was to take photographs of the same wound using a 10-megapixel digital camera and posterior measurement of the area using ImageJ software (National Institutes of Health, Bethesda, Md) by one operator. The mean area of the wounds was 12.20 ± 10.45 cm2 for imito and 12.67 ± 10.86 cm2 for ImageJ measurement. The interclass correlation coefficient (ICC) between ImageJ and imito was 0.978 for a single measure and 0.989 for the average measure. Considering the two measurements, the ICC demonstrated excellent interobserver correlation using imito (0.987). Larger wounds had a greater difference between the methods (4.28% greater with the ImageJ measurement when considering areas >9 cm2). No difference was found between iOS (ICC, 0.995) and android (ICC, 0.970) smartphone operating systems. The smartphone application is a useful method for area measurement with excellent accuracy compared with digital photography and the ImageJ processing tool.

WIfI Classification Versus Angiosome Concept: A Change in the Infrapopliteal Angioplasties Paradigm.

OBJECTIVE: The objective of this study was to determine whether the angiosome concept and WIfI classification in patients undergoing endovascular treatment is associated with the limb salvage rate and wound healing rate in patients with critical limb ischemia(CLI). METHODS: This was a retrospective, consecutive cohort study of CLI patients who underwent infrapopliteal angioplasty at the Vascular and Endovascular Surgery Service of the Hospital do Servidor Público Estadual, São Paulo, between January 2013 and January 2019. The primary outcome variable was the limb salvage rate and wound healing rate. The secondary outcome variables were patency, survival, time free from reintervention, and operative mortality rate. RESULTS: Overall, 95 infrapopliteal endovascular procedures were performed in 95 patients. The initial technical success rate was 100%. The mean ± standard deviation outpatient follow-up time was 775 ± 107.5 days. The analyses were performed at 360 days for wound healing rate and 720 days for limb salvage rates, overall survival, and time freedom from reintervention. According to the angiosome concept, there were 54 patients (56.8%) classified in the direct group and 41 patients (43.2%) in the indirect group. Regarding the WIfI classification subanalysis, there were 22 patients WIfI 0-1 (23.2%) and 73 patients WIfI 2-3 (76.8%). Furthermore, the indirect group had a higher ulcer healing rate than the direct group; however, it was not statistically significant (82.9%; 66.7%%, respectively, P = 0.059). However, the time to heal the ulcer was faster in the WIfI 0-1 groups than WIfI 2-3 groups (164.82 days versus 251,48; P = 0.017). The limb salvage rates at 720 days were similar among indirect and direct Groups (92.6% and 85.4%, P = 0.79). Likewise, the freedom from reintervention rates at 720 days were also similar in Indirect and direct groups (74.6% and 64%, P = 0.23). The survival rates at 720 days were similar in both indirect and direct groups (86.8 and 85.6%, respectively; P = 0.82). The amputation free survival rate at 720 days by the Kaplan-Meier method was 91.3% in the indirect group and 85.9% in the direct group, but with no statistical significance between the groups (P = 0.37) CONCLUSIONS: This study concluded that, in endovascular treatment, the angiosome concept is no longer important to limb salvage rates, nor ulcer/wound healing rates. Moreover, the WIfI classification 0-1 is associated with faster and higher wound/ulcer healing rates than WIfI classification 2-3.

Rationale and design for the study Apixaban versus ClopidoGRel on a background of aspirin in patient undergoing InfraPoPliteal angioplasty for critical limb ischemia: AGRIPPA trial.

BACKGROUND: New antithrombotic strategies that reduce primary thrombosis and restenosis might improve vascular outcomes in patients with peripheral artery disease (PAD) undergoing arterial angioplasty. The study objective is to evaluate the potential benefit of apixaban plus aspirin compared with standard of care dual antiplatelet therapy (DAPT) in reducing thrombotic restenosis and artery re-occlusion in patients undergoing endovascular infrapopliteal revascularization. STUDY DESIGN: This multicenter, parallel-group, prospective, randomized, open-label, blinded-endpoint adjudication, proof-of-concept, exploratory trial aims to randomize 200 patients 72 hours after successful infrapopliteal angioplasty for critical limb ischemia (CLI). Patients will be randomly assigned in a 1:1 ratio to receive oral apixaban (2.5 mg twice daily) plus aspirin (100 mg once daily) for 12 months or clopidogrel (75 mg daily) for at least 3 months on a background of aspirin (100 mg once daily) for 12 months. The primary endpoint is the composite of target lesion revascularization (TLR), major amputation, or restenosis/occlusion (RAS) in addition to major adverse cardiovascular events - MACE (myocardial infarction, stroke or cardiovascular death) at 12 months. The primary safety endpoint is the composite of major bleeding or clinically relevant non-major bleeding at 12 months. SUMMARY: This study will evaluate the efficacy and safety of apixaban 2.5 mg twice daily plus aspirin compared with DAPT (clopidogrel plus aspirin) in patients with CLI undergoing endovascular infrapopliteal revascularization and might prove the concept of an alternative antithrombotic regimen for these patients to be tested in a future large randomized clinical trial.

Ultrasound Aspects and Recanalization Rates in Patients with Lower-Limb Deep Venous Thrombosis Treated with Rivaroxaban.

BACKGROUND: In this article, we report the ultrasound aspects and recanalization rates of patients with deep venous thrombosis (DVT) in the lower limbs treated with the rivaroxaban, focusing on the recanalization rate and the ultrasonographic aspects. METHODS: This was a prospective and consecutive cohort study of patients admitted with DVT who were submitted to treatment with rivaroxaban for 6 months at the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual, São Paulo, Brazil, between March 2016 and July 2018. RESULTS: Fifty-one patients with DVT were admitted to the Vascular Surgery Department and received rivaroxaban for 6 months. The follow-up time was 360 days. Analyses were performed at 180 and 360 days. The rate of total venous recanalization at 360 days was 76.4% (39 patients). The incidence of partial venous recanalization was 23.5% (12 patients). At the first month, 11 patients (21.7%) continued with total occlusion of the vein, with 4 patients (6.5%) with no residual thrombi. However, at 6 months, only 2 patients (2.2%) continued with total occlusion of the vein, with 26 patients (47.8%) with no residual thrombi. At 12 months, there were 39 patients (76.4%) with no residual thrombi. Univariate and multivariate logistic regression identified the following factors related to total venous recanalization: the absence of popliteal vein reflux (odds ratio [OR], 0.386; P = 0.007), no residual thrombi (OR, 3.213; P = 0.008), femoropopliteal clot length at 1 month (OR, 3.021; P = 0.016), femoropopliteal clot length at 6 months (OR, 2.234; P = 0.008). The incidence of post-thrombotic syndrome (PTS) at 12 months was 8.3%. CONCLUSIONS: In this study, patients who received oral rivaroxaban displayed satisfactory total vein recanalization rate after 6 months and 12 months. The factors associated with better total recanalization rates were the absence of popliteal vein reflux, the absence of residual thrombi in the veins, femoropopliteal clot length at 1 month (OR, 3.021; P = 0.016), and femoropopliteal clot length at 6 months (OR, 2.234; P = 0.008). Moreover, the incidence of PTS at 12 months was 8.3%.

Comparison of Bypass and Endovascular Intervention for Popliteal Occlusion with the Involvement of Trifurcation for Critical Limb Ischemia.

BACKGROUND: The aim of this study is to analyze the technical aspects and outcomes of the treatment of occlusion of the popliteal artery with the involvement of the trifurcation treated with a bypass (open) and endovascular (endo) approach. METHODS: Overall, 108 consecutive procedures were enrolled retrospectively. Patients were evaluated in 2 groups: the endo group (65 patients) and the open group (43 patients). Primary outcome were MALE (major adverse limb events), amputation-free survival, and early mortality (until 30 days). Secondary outcome was overall survival in 3 years. Inclusion criteria were Rutherford 4 and 5 and occlusion of the popliteal artery with the involvement of trifurcation and, at least, 1 infrapopliteal artery of runoff. RESULTS: Technical success was achieved in 100% of patients in the open and 96.9% of patients in the endo group. Freedom from MALE was 73.5% and 68.5% for 1 and 3 years respectively for the endo group, and 84.3% and 77.2% respectively for the open group (P = 0.413). Considering the total number of major reinterventions executed until 3 years, the reinterventions was statistically more performed in the endo compared to the open group (P = 0.0459). Amputation-free survival for the endo group in 30 days, 1 year, and 3 years was 93.7%, 79.3%, and 66.0%, respectively, and the amputation-free survival for the open group was 88.4%, 77.4%, and 64.3% (P = 0.726). Early mortality was 9.3% for the open group and 1.5% for the endo group (P = 0.060). In 3 years, the overall survival was 75.1% in the open group and 84.3% in the endo group. CONCLUSIONS: In 3 years, follow-up endovascular treatment of occlusion of the popliteal artery with the involvement of the trifurcation has similar time freedom from MALE compared to open approach. Overall and amputation-free survival was not different between the groups besides more reinterventions in patients who underwent endovascular approach.

The outcomes of internal iliac artery preservation during endovascular or open surgery treatment for aortoiliac aneurysms.

BACKGROUND: Internal iliac artery (IIA) preservation continues to be a challenge during open surgery or endovascular repair of abdominal aortoiliac aneurysm (AAIA). OBJECTIVES: To determine the results in terms of survival and clinical outcomes in patients with aortoiliac aneurysms (AAIA) treated with endovascular (EV) or open surgical (OS) repair. METHODS: This was a retrospective consecutive cohort study of patients with AAIA who underwent EV or OS repair. RESULTS: Post-procedure hospitalization time and intensive care unit stay were both longer in the OS group than in the EV group (7.08 ± 3.5 days vs. 3.32 ± 2.3 days; p = 0.03; 3.35 ± 2.2 days vs. 1.2 ± 0.8 days; p = 0.02, respectively). There were two cases of bowel ischemia (4.7%; OS 8.3% and EV 3.2%; p = 0.48), two cases of buttock claudication (4.7%; OS 8.3% and EV 3.2%; p = 0.48), and one case of sexual dysfunction (2.3% OS), all of them in patients with bilateral occlusion of the internal iliac artery (five patients, 11.6%; p = 0.035). Overall survival at 720 days was 80.6% in the EV group and 66.7% in the OS group (p = 0.58). CONCLUSIONS: In the present study, OS and EV repair of aortoiliac aneurysms had similar overall survival and outcomes. Preservation of at least one internal iliac artery is associated with good results and no further complications.

CONTEXTO: A preservação de uma artéria ilíaca interna continua a ser um desafio terapêutico nos pacientes com aneurismas aorto-ilíacos submetidos tanto ao tratamento endovascular quanto a cirurgia aberta. OBJETIVOS: Determinar os resultados da sobrevida e desfechos clínicos em pacientes com aneurismas aorto-ilíacos (AAIA) que recebem reparo endovascular (EV) ou cirúrgico aberto (CA). MÉTODOS: Este foi um estudo de coorte consecutivo e retrospectivo de pacientes com AAIA submetidos a reparo EV ou CA. RESULTADOS: Houve maior tempo de internação pós-procedimento e permanência na unidade de terapia intensiva no grupo CA comparado com o grupo EV (7,08±3,5 dias vs. 3,32±2,3 dias; p = 0,03; 3,35±2,2 dias vs. 1,2±0,8 dias; p = 0,02, respectivamente). Houve dois casos de isquemia intestinal (4,7%; CA 8,3% e EV 3,2%; p = 0,48), dois casos de claudicação das nádegas (4,7%; CA 8,3% e EV 3,2%; p = 0,48) e um caso de disfunção sexual (2,3% CA), todos em pacientes com oclusão bilateral da artéria ilíaca interna (AII) (cinco pacientes, 11,6%; p = 0,035). A sobrevida global aos 720 dias foi de 80,6% no grupo EV e de 66,7% no grupo CA (p = 0,58). CONCLUSÕES: No presente estudo, o EV e o CA para aneurismas aorto-ilíacos apresentaram sobrevida e desfechos clínicos semelhantes. A preservação de pelo menos uma AII está associada a bons resultados e sem complicações adicionais.

Analysis of the Safety and Efficacy of the Endovascular Treatment for Acute Limb Ischemia with Percutaneous Pharmacomechanical Thrombectomy Compared with Catheter-Directed Thrombolysis.

BACKGROUND: To evaluate the rates of limb salvage, survival, and perioperative mortality in patients with acute limb ischemia (ALI) submitted to endovascular revascularization with pharmacomechanical thrombectomy (PMT) and catheter-directed thrombolysis (CDT). METHODS: This was a retrospective consecutive cohort study of patients with ALI who were submitted to endovascular treatment with PMT or fibrinolysis at the Division of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual (São Paulo, Brazil), between July 2015 and December 2018. The limb salvage rate and survival rate at 720 days were analyzed in both the PMT (group 1) and CDT treatment (group 2), as well as the perioperative mortality rate (PMR) at 30 days after surgery. RESULTS: One hundred twelve patients were admitted to the emergency department with ALI between July 2015 and December 2018. Seventeen patients diagnosed with Rutherford III irreversible ALI and 46 patients submitted to open surgery were excluded. Thus, 49 patients were submitted to endovascular surgery; 18 (36.7%) were classified into group 1, and 31 (63.3%) were classified into group 2. The clinical data were equal between the 2 groups, but there was a higher prevalence of thrombophilia in group 1 (3 cases; P < 0.001). The limb salvage rate and the overall survival rate at 720 days were similar between groups 1 and 2 (87.8% vs. 89.7%, P = 0.78 and 84.7% vs. 69.2%, P = 0.82, respectively). There was no statistical difference regarding secondary patency rates at 720 days between groups 1 and 2 (group 1, 81.9% and group 2, 78.8%; P = 0.66). The PMR was 16.7% (8 patients) within the first 30 days. Group 2 had a higher overall mortality rate (OMR) (6 patients, 19.3%, P = 0.03). Regarding the PMT group, there was a higher rate of complications such as myoglobinuria, hematuria, acute renal failure, and death in the subgroup of patients in whom there were performed more than 150 cycles/sec during the surgery (P < 0.001). CONCLUSIONS: In the present study, the PMT and CDT endovascular procedures had similar limb salvage, overall survival, and secondary patency rates. However, the OMR was higher in the CDT group. Another important finding was related to the number of cycles/sec performed in the PMT group, in whom patients with more than 150 cycles/sec have presented with higher rates of hematuria, myoglobinuria, acute renal failure, and death.