Role of Anticoagulation in Nonagenarian Patients with Acute Limb Ischemia.

BACKGROUND: Preoperative anticoagulant therapy is known to have a positive impact on the prognosis of patients with acute limb ischemia (ALI). However, little is known about its efficacy in elderly patients. We aimed to investigate the potential effect of anticoagulation in nonagenarian patients managed for ALI. METHODS: Between January 2015 and December 2021, we identified all nonagenarian patients managed for ALI at a single center. Long-term anticoagulation and hemostasis parameters (prothrombin rate, activated partial thromboplastin time [APTT], platelet count) measured on admission were reviewed. The primary end point was mortality at 30-day mortality (D30) in patients with or without long-term anticoagulation therapy. We also studied the effect of these factors on the occurrence of revascularization failure in operated patients (initial failure, ischemic recurrence during hospitalization, necrosis requiring major amputation). RESULTS: A total of 68 nonagenarian patients were managed for ALI, with a mean age of 93.8 years (from 90-107 years), 76.5% of whom were women. Of these patients, 47 (69%) were managed surgically. Long-term anticoagulation therapy was associated with better survival at D30, both in nonoperated (P < 0.01) and operated (P < 0.05) patients. In operated patients, the absence of long-term anticoagulation therapy was associated with the occurrence of revascularization failure (P < 0.05). In operated patients, survival to D30 and successful revascularization were associated with a longer APTT (P < 0,05). We were able to observe the survival of 4 patients contraindicated for surgery and treated with a single medical therapy (intravenous unfractionated heparin). CONCLUSIONS: Anticoagulation appears to have an impact on the survival and postoperative prognosis of nonagenarian patients with ALI. In addition, curative anticoagulation therapy may be an alternative treatment when surgery is contraindicated in this frail population.

Radial artery deviation and reimplantation inhibits venous juxta-anastomotic stenosis and increases primary patency of radial-cephalic fistulas for hemodialysis.

OBJECTIVE: Although the end cephalic vein-to-side radial artery arteriovenous fistula is the "gold standard" procedure for primary hemodialysis access, it is associated with high rates of primary failure because of the development of neointimal hyperplasia and juxta-anastomotic stenosis. We report initial results of a new approach to perform radial-cephalic fistulas, radial artery deviation and reimplantation (RADAR), designed to avoid juxta-anastomotic stenosis. METHODS: RADAR patients' data were prospectively maintained and retrospectively reviewed and compared with a historical control group of traditional radial-cephalic fistulas created in the same center. Duplex ultrasound was used to monitor maturation (flow ≥500 mL/min and venous diameter ≥5 mm) and to diagnose juxta-anastomotic stenosis. Study end points were rates of maturation, juxta-anastomotic stenosis, reintervention, and primary and secondary patency. RESULTS: There were 53 RADAR fistulas performed (follow-up, 10.5 ± 2.6 months) and compared with 73 control fistulas (follow-up, 12.0 ± 6.6 months). RADAR fistulas had increased rates of maturation compared with control fistulas (75% vs 45% at 6 weeks, P = .001; 92% vs 71% at 3 months, P = .003) and decreased incidence of juxta-anastomotic venous stenoses (2% vs 41%; P = .001). At 6 months, RADAR fistulas had increased primary patency (93% vs 53%; P < .0001) and secondary patency (100% vs 89%; P = .0003) and decreased incidence of reinterventions (10% vs 74%; P = .001) compared with control fistulas. No RADAR fistulas caused ischemic symptoms. CONCLUSIONS: The RADAR technique is associated with less juxta-anastomotic stenosis, increased maturation and patency, and fewer secondary interventions. These improved outcomes suggest that RADAR may be the preferred surgical technique to perform radial-cephalic arteriovenous fistula.

Salvage of Early-Failing Radiocephalic Fistulae with Techniques that Minimize Venous Dissection.

Although radiocephalic fistulae are the preferred hemodialysis access, juxta-anastomotic stenosis is often responsible for early fistula failure. We hypothesized that wall ischemia from surgical manipulation leads to early juxta-anastomotic neointimal hyperplasia and failure of maturation and that minimal venous dissection will improve surgical salvage, increasing fistula maturation rates. For failing-to-mature radiocephalic fistulae that develop early juxta-anastomotic stenosis, we describe 3 variations to perform a new proximal anastomosis with a minimal dissection technique on the forearm cephalic vein: (1) side-to-side anastomosis, (2) radial artery deviation and reimplantation, or (3) radial artery deviation and loop reimplantation. Minimal dissection of the cephalic vein achieves fistula salvage without needing a more proximal site for access.

Successful treatment of a spontaneous rupture of the left external iliac vein in a man.

Spontaneous rupture of the external iliac vein associated with a May-Thurner syndrome is infrequent, particularly in men. We report a case of previously healthy 73-year-old man with a left iliac vein thrombosis, who presented a large lower left abdominal hematoma of sudden-unset. Emergent laparotomy revealed a 3-cm longitudinal tear in the left external iliac vein, which was repaired primarily. Patient's recovery was uneventful. Possible etiological factors have been identified as venous hypertension due to iliac vein thrombosis associated with Cockett syndrome, as well as inflammatory venous wall. Some other estrogenic factors could explain female preponderance of the event.

Axillary loop grafts for hemodialysis access: midterm results from a single-center study.

PURPOSE: This study reports our midterm results with arteriovenous axillary loop grafts (AVALG) and evaluates their role in construction of vascular access for patients on chronic hemodialysis. METHODS: The clinical data of 27 patients who underwent construction of an AVALG for hemodialysis access at our institution between July 2002 and December 2006 were analyzed retrospectively. Outcome measures included graft patency, the complication rate, and the frequency and morbidity of secondary procedures after AVALG creation. The Kaplan-Meier method was used to calculate the primary and secondary patency curves. RESULTS: AVALG was constructed as the first access procedure in eight patients: five patients with no suitable vein to construct an adequate angioaccess on the upper limbs, and three patients with elbow and forearm arteritis. The 19 other patients had all had two to five failed prior vascular accesses leading to exhaustion of venous access sites on the upper extremities (18 cases), or a steal syndrome (one case). No postoperative death occurred, but four patients died of causes unrelated to the intervention between the second and the tenth postoperative months. The mean follow-up was 15 months (range, 2-48 months). The primary patency rate at 12 months and the secondary patency rate at 18 months were 51% and 80%, respectively. Infection (three cases), thrombosis (seven cases), and stenosis of the outflow vein (two cases) were the main complications, occurring in 10 of the 27 patients (41%). Twelve secondary procedures were performed in these 10 patients with little additional morbidity. Five of the 27 patients developed irreversible AVALG occlusion leading to access loss: two patients with concomitant graft infection and three patients with a history of subclavian vein catheterization. CONCLUSION: AVALG may represent a supplementary option for chronic hemodialysis patients with vascular steal or inadequate upper extremity venous access sites.

Iliac conduit for renal and visceral artery access during endovascular repair of a pararenal aneurysm with a fenestrated stent-graft.

PURPOSE: To report a technique for fenestrated stent-graft repair involving a conduit implanted at the origin of a patent aneurysmal common iliac artery (CIA) in a patient with a pararenal aortic aneurysm and iliac artery occlusion. CASE REPORT: A 60-year-old man with multiple comorbidities presented with an 8-cm abdominal aortic aneurysm (AAA) with no infrarenal neck according to computed tomography (CT). Both CIAs were aneurysmal; the left was occluded, as were the left internal and external iliac arteries and the inferior mesenteric artery. Two patent accessory renal arteries were depicted. Because an infrarenal neck was absent, treatment with a fenestrated endograft was performed under general anesthesia. The right CIA was approached via an oblique retroperitoneal incision. A 10-mm polytetrafluoroethylene tube graft was implanted on the origin of the right CIA aneurysm in an end-to-side fashion to facilitate delivery of a Zenith endograft constructed with 2 small fenestrations for the renal arteries, 1 large strut-free fenestration for the superior mesenteric artery, and a scallop for the celiac trunk. The proximal fenestrated body of the Zenith device was introduced via the right iliac artery by direct puncture of the common femoral artery. The conduit was used to cannulate the 3 fenestrations for subsequent deployment and for delivery of the distal Zenith aortomonoiliac device. The procedure was completed successfully, but 12 hours after surgery, the patient developed a significant right retroperitoneal hematoma, which was treated surgically. CT confirmed patency of all visceral arteries and no endoleak. One month after the initial procedure, he had recovered totally and was discharged. CONCLUSION: Iliac conduits could widen the feasibility of fenestrated endografting in patients unfit for open surgery with pararenal aneurysms and challenging iliac anatomy. However, this adjunctive procedure has its own morbidity.

Percutaneous angioplasty of the superior gluteal artery for buttock claudication: a report of seven cases and literature review.

BACKGROUND: Buttock claudication due to stenosis or occlusion of the superior gluteal artery is infrequent. The recent development of noninvasive gluteal duplex scanning, combined with aortoiliac angiography using oblique projections and the availability of low-profile devices for percutaneous transluminal angioplasty (PTA), led us to review our recent experience concerning the diagnosis and mid-term results of PTA for superior gluteal artery stenosis or occlusion. METHODS: The files of all patients who had been treated in our department by PTA for superior gluteal artery stenosis or occlusion with buttock claudication were analyzed retrospectively, and any associated arterial lesions, morbidity, restenosis, or recurrent buttock claudication were noted. Outcomes were compared with published reports. RESULTS: Retrospective review identified six patients (5 men, 1 woman; mean age, 64 years) with seven cases of buttock claudication (1 bilateral localization) who had undergone PTA within the past 2 years. There was no case of isolated buttock claudication. Buttock claudication was associated with impotence, thigh claudication, or calf claudication in seven cases. Gluteal duplex scans were performed for three of the patients diagnosed with two stenoses and one occlusion. Aortoiliac angiography revealed five superior gluteal artery stenoses and two occlusions. PTA without stenting was successful in all cases, without morbidity or mortality. During a mean follow-up of 13 months, restenosis occurred in one patient. A repeat PTA without stenting was successful, with resolution of the buttock claudication. CONCLUSIONS: Buttock claudication due to superior gluteal artery stenosis is probably underestimated when gluteal duplex scanning and aortoiliac angiography with oblique projections are not performed. PTA gives good results, and the procedure can be repeated should restenosis occur.

Acute compartment syndrome: an unusual complication of a previously bypassed popliteal aneurysm--case report and literature review.

An acute compartment syndrome of the calf due to popliteal vein compression is described in a 71-year-old man who had undergone popliteal aneurysm bypass and ligation 10 years previously. Acute pain and extensive edema of the right leg and a pulsatile mass in the right popliteal fossa prompted arteriography that revealed collateral filling of the aneurysm. Aneurysm decompression by using a posterior approach was completed, including genicular artery ligation, and fasciotomy was performed. Irreversible ischemia of the foot necessitated tibial amputation on the third day after surgery. The literature on complications of excluded popliteal aneurysms after bypass and ligation, clinical presentations, and surgical management is reviewed.