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.

Impact of Target Visceral Vessel Anatomical Configuration on Early Complications Following Endovascular Repair of Thoracoabdominal Aortic Aneurysms.

BACKGROUND: Fenestrated and branched endovascular aortic repair (fEVAR-bEVAR) is a viable treatment option for thoracoabdominal aortic aneurysms but target visceral stent (TVS) endoleak and thrombosis remain a limiting factor. This study aims to evaluate TVS anatomy impact on 1-year risk of thrombosis and endoleak. METHODS: Patients treated with fEVAR-bEVAR for thoracoabdominal aneurysms between 2008 and 2020 in our centre were enrolled. We recorded comorbidities, operative details, 1-month postoperative CT scan (anatomical reference), and TVS behaviour: thrombosis and endoleak at 1-year follow-up. For each TVS, different points were identified using a centre-lumen-line: (A) TVS origin, (B) end of branch/fenestration, (C) visceral vessel entry, (D) end of TVS, (E) 1-cm distally. We analyzed TVS tortuosity ((centre-lumen-line/straight distance)-1, in %), image vector analysis of each segment in 2D (antero-posterior, left-right) and 3D (craneo-caudal displacement), and centre-lumen-line analysis (bending in ABC and CDE). Three independent observers performed a blind analysis, and anatomical differences between bEVAR/fEVAR, and cases with/without 1-year thrombosis and TVS endoleak, were compared using Kaplan-Meier curves (Log-Rank test), and t-test/Wilcoxon signed-ranks test respectively. RESULTS: Fifty-four patients (72 ± 713 years mean age; 182 TVS: 50 branches, 132 fenestrations) met the inclusion criteria. bEVAR cases had longer stents, with more caudal 3D angulation, and greater ABC angulated segment. After excluding bEVAR cases (low case number), 97 fEVAR TVS were analyzed. Five thrombosis and 7 endoleaks were observed. While anatomical configuration showed no association to thrombosis, it was related to endoleak: these cases presented more tortuous stents (5.97% ± 0.10, 21.40% ± 0,22, P = 0.011), with more angulated centre-lumen-line at ABC segment (5.69° ± 15.77°, 7.18° ± 7.77°, P = 0.012), and more upward-pointing stents in the origin of the stent (AB: 89.07° ± 24.46°, 109.09° ± 16.56°, P = 0.012; BC: 87.86° ± 21.10°, 113.11° ± 22.23°, P = 0.026). CONCLUSIONS: Anatomical configuration of the TVS is associated with type III endoleak, but not thrombosis, at 1-year following fEVAR. Cases with endoleak presented more tortuous stents, with a more angulated exit from the endograft, and upward-pointing of the origin of the stent.

Angioplastia guiada mediante eco Doppler en el tratamiento de las estenosis de fístula arteriovenosa para hemodiálisis / Ultrasound-guided angioplasty in the treatment of arterio-venous fistula stenosi

INTRODUCCIÓN: las estenosis en el trayecto de fístulas arteriovenosas (FAV) para hemodiálisis son un problema muy prevalente y existe una larga experiencia en su tratamiento mediante angioplastia percutánea (ATP). Estos procedimientos, sin embargo, implican unas necesidades no despreciables de aparataje, exposición a radiación y contraste intravenoso que no son beneficiosas para el paciente y hacen más compleja su realización. Este estudio revisa nuestra experiencia inicial en la angioplastia guiada mediante ecografía Doppler. MATERIAL Y MÉTODOS: cohorte prospectiva de pacientes con disfunción de la FAV nativa por estenosis venosas significativas tratados mediante una ATP guiada mediante eco Doppler. La punción de la FAV, la cateterización de la lesión, la localización y el inflado del balón y la comprobación del resultado se hicieron de forma ecoguiada. Tan solo se realizaron una fistulografía comprobatoria previa y otra posterior a la dilatación. Como control, se recogieron también los casos realizados durante el mismo periodo por el método angiográfico habitual. RESULTADOS: entre febrero de 2015 y septiembre de 2018 se realizaron 51 ATP sobre FAV nativa, de las que 27 fueron de forma ecoguiada (edad media, 65,3 años; 63% varones). El éxito técnico fue del 96%. En el 26% de los casos se repitió la ATP por estenosis residual tras la imagen angiográfica. Hubo un 7,3% de complicaciones periprocedimiento. El 92% de las FAV fueron puncionadas a las 24 h. La permeabilidad primaria a 1 mes, 6 meses y 1 año fue del 100%, 64,8% y 43,6%, y la asistida del 100%, 87,2% y 74,8%. No hubo diferencias significativas en los resultados inmediatos o tardíos respecto a las angioplastias de FAV guiadas mediante angiografía. CONCLUSIONES: la ATP-FAV puede realizarse de manera segura y eficaz guiada mediante ecografía Doppler, lo que permite simplificar la logística necesaria para su realización, si bien debemos mejorar todavía la capacidad de comprobación precoz del resultado con esta técnica de imagen

BACKGROUND: stenoses in the arterio-venous fistulae (AVF) for hemodialysis are a very common problem and there is a long experience in its treatment by percutaneous angioplasty (PTA). These procedures, however, imply important needs for equipment, exposure to radiation and intravenous contrast that are not beneficial for the patient and make it more complex to perform. This study reviews our initial experience in ultrasound-guided angioplasty. MATERIAL AND METHODS: prospective cohort of patients with native AVF dysfunction due to significant venous stenosis, undergoing a PTA ultrasound-guided. Puncture of the AVF, catheterization of the lesion, localization and inflation of the balloon and verification of the result were ultrasound-guided, with only a fistulography performed before and after the dilation. As a control-cases, patients intervened by the usual angiographic method were also collected. RESULTS: of the 51 ATP performed on native AVF between February 2015 and September 2018, 27 were ultrasound-guided (mean age 65.3 years, 63% males). The technical success was 96%. In 26% of the cases, ATP was repeated due to residual stenosis after the angiographic image. There were 7.3% peri-procedural complications. 92% of the AVF were punctured at 24 h. Primary patency rates at 1 month, 6 months and 1 year was 100%, 64.8% and 43.6% and Assisted 100%, 87.2% and 74.8%, respectively. There were no significant differences in the immediate or late results with respect to angioplasty of AVF guided by angiography. CONCLUSIONS: ATP-FAV can be safe and effectively performed by Doppler ultrasound guidance. This method simplifies the logistics of the procedure although further improvements are needed to ensure that ultrasound is adequate to ensure the correct patency of the vessel

Disease Progression in the Contralateral Carotid Artery is Still Common After Endarterectomy.

BACKGROUND: Disease progression in the contralateral carotid artery (CA) after a carotid endarterectomy (CEA) was common in the past. Current medication regimens for these patients are better and have probably modified this progression. We evaluated the rate of disease progression in the contralateral CA over the last decade. METHODS: A retrospective analysis of 291 consecutive patients undergoing a CEA between 2005 and 2014 was performed. Disease progression in the contralateral CA after CEA was determined by a duplex ultrasound. Statistics were calculated by Kaplan-Meier life-tables and Cox regression. RESULTS: Of the 291 patients, 246 (84.5%) received at baseline antiplatelet and/or anticoagulant agents, and 223 (77%) received statins. These proportions increased over the second half of the study. Disease progression in the contralateral CA was evaluated in 200 patients during a mean follow-up of 3.5 years. Progression-free survival rates from any disease progression at 1 and 5 years were of 89.3% and 68.6%, respectively. Free survival rates from <50% to >50% progression or from 50% to 69% to a higher category at 1 and 5 years were of 89.3% and 75.5%, respectively. Finally progression-free survival rates to a >70% stenosis or occlusion at 1 and 5 years were of 96.8% and 90.1%, respectively. Age (hazard ratio = 1.034, P = 0.048) and dyslipidemia (hazard ratio = 1.93, P = 0.045) were also associated with any disease progression. CONCLUSIONS: Current rates of disease progression in the contralateral CA after CEA are similar to those reported more than 1 decade ago. Further research will be needed to evaluate the impact of current medical regimens at these stages of disease.

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.

Long-term Survival after Carotid Endarterectomy in a Population with a Low Coronary Heart Disease Fatality: Implications for Decision Making.

BACKGROUND: According to the current guidelines, long-term survival is an important factor influencing decision making in patients with severe asymptomatic carotid stenosis. Nevertheless, data are lacking for populations with a low incidence of coronary heart disease, the main cause of death among these patients. We aimed to assess the long-term survival after carotid endarterectomy (CEA) in a Mediterranean hospital. METHODS: Retrospective analysis was conducted of 291 consecutive patients (main age 69 years, 78.7% men) who underwent a CEA for symptomatic (n = 147, 50.5%) or asymptomatic (n = 144, 49.5%) carotid stenosis in 2005-2014 at the Hospital del Mar (Barcelona, Spain). A Kaplan-Meier life table was done and a multivariable Cox regression model was built for the analysis of the long-term survival-associated risk factors. RESULTS: The immediate combined mortality and/or neurological morbidity rate was 2.7%. The mean follow-up was 55 months (complete in 99.7%). During follow-up 62 patients (21.3%) died, being cancer the most frequent cause (35.5%). Cumulative 3- and 5-year survival rates were 89% and 81%, respectively. Independent risk factors (Cox regression) related to survival included age (hazards ratio [HR] 1.09, P < 0.001), an American Society of Anesthesiologists class IV score (HR 4.04, P = 0.015), and the preoperative hemoglobin value (HR 0.73, P < 0.001). The discrimination of the resulting model was 0.719 (95% confidence interval 0.644-0.794). Previous symptomatic carotid stenosis was not related to long-term survival. CONCLUSIONS: The long-term survival of patients submitted to CEA in our series lies in the lower limit of the estimated range by other groups and is markedly related to cancer. Our study suggests that predictive models for survival are influenced by regional characteristics.

Survival After Endovascular Abdominal Aortic Aneurysm Repair in a Population with a Low Incidence of Coronary Artery Disease.

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) is a prophylactic procedure, so the decision to operate should consider, as recent guidelines suggest, the life expectancy of the patient. Several models for predicting life span have been already designed, but little is known about how intervened patients evolve in Southern European Countries, where the incidence of coronary artery disease, the main cause of death among these subjects, is low. METHODS: We conducted a retrospective analysis of 176 consecutive patients who underwent elective EVAR at the Vascular Surgery Department of the Hospital del Mar (Barcelona, Spain) during 2000-2014. Cox regressions were performed to identify preoperative factors associated with long-term survival after EVAR, and a risk model was developed. RESULTS: Three- and five-year survival rates were 73.9 and 53.9 %, respectively. During the follow-up, 72 deaths (40.9 %) were registered, cancer being the most frequent cause (41.7 %). Preoperative variables negatively associated with long-term survival were serum creatinine ≥ 150 µmol/L (HR 2.5; 95 % CI 1.4-4.2), chronic obstructive pulmonary disease (HR 1.9; 95 % CI 1.2-3.1), atrial fibrillation (HR 2.0; 95 % CI 1.2-3.4), and prior cancer history (HR 1.9; 95 % CI 1.2-3.1). Distal pulses present in both lower limbs were marginally associated with survival (HR 0.65; 95 % CI 0.4-1.07). The survival predictive model showed a good discrimination capacity (C statistic = 0.703; 95 % CI 0.641-0.765). CONCLUSIONS: Long-term survival of patients submitted to EVAR in our setting was worse than expected and markedly related to cancer. Our study suggests that predictive models for long-term survival after EVAR may be influenced by regional characteristics of the intervened population. This effect should be taken in consideration in the decision-making process of these patients.