Infrapopliteal 3-Vessel Occlusive Disease Is the Only Predictor of Wound Recurrence After Complete Wound Healing via Endovascular Therapy in Patients With Chronic Limb-threatening Ischemia.

PURPOSE: To determine the predictors of wound recurrence after complete wound healing in patients with chronic limb-threatening ischemia (CLTI) who underwent endovascular therapy (EVT) for infrapopliteal (IP) lesions with consideration of IP arterial anatomic severity, including classification by the Global Limb Anatomic Staging System (GLASS). MATERIALS AND METHODS: This retrospective single-center study assessed patients with de novo CLTI limbs with tissue loss treated via EVT for IP lesions from September 2016 to May 2021. Among these patients, 149 consecutive limbs from 133 patients who achieved complete wound healing were enrolled. The Kaplan-Meier method was used to estimate the wound recurrence rate after complete wound healing. The Cox proportional hazard model was used to assess the association between baseline characteristics and wound recurrence. RESULTS: The cumulative wound recurrence rate 1 year after complete wound healing was 30%. The mean time for wound recurrence was 7±5 months. Only IP arterial anatomic characteristics remained as a predictor of wound recurrence, whereas wound status and management, including the Wound, Ischemia, and foot Infection (WIfI) clinical stage and minor amputation, were not associated with wound recurrence. Multivariate analysis revealed independent associations between wound recurrence and IP 3-vessel occlusive disease (hazard ratio, 2.97; 95% confidence interval, 1.39-6.35), but not poor below-the-ankle runoff, IP Peripheral Arterial Calcium Scoring System (PACSS) grade, and the GLASS IP grade. CONCLUSION: The only independent predictor of wound recurrence after complete wound healing via EVT in patients with CLTI was IP 3-vessel occlusive disease. CLINICAL IMPACT: In patients with chronic limb-threatening ischemia (CLTI), wound recurrence after complete wound healing remains a challenge, and studies focused exclusively on wound recurrence are still limited. The present study aimed to determine the risk factors for wound recurrence after complete wound healing in patients with CLTI who underwent endovascular therapy (EVT) for infrapopliteal (IP) lesions, with consideration of IP arterial anatomic severity for the first time. The results showed that IP 3-vessel occlusive disease was the only predictor of wound recurrence, whereas wound status/management and other arterial anatomic characteristics including WIfI clinical stages and GLASS grades were not predictors.

High Global Limb Anatomic Staging System Femoropopliteal Grade is Positively Associated with Wound Healing in Patients with Chronic Limb-Threatening Ischemia Undergoing Endovascular Therapy Only for Femoropopliteal Disease.

BACKGROUND: To investigate the prognostic impact of femoropopliteal (FP) arterial anatomic severity including classification by the global limb anatomic staging system (GLASS) on wound healing in patients with chronic limb-threatening ischemia (CLTI) who had undergone endovascular therapy (EVT) only for FP lesions. METHODS: This was a retrospective single-center study. We treated 349 consecutive de novo CLTI limbs with tissue loss from January 2017 to May 2021. Among these, 91 limbs treated via EVT only for FP lesions were enrolled. We compared the clinical background, infrapopliteal (IP)/FP arterial anatomical characteristics, and EVT results between the limbs with GLASS FP grade 1 or 2 (low GLASS FP, n = 20) and those with GLASS FP grade 3 or 4 (high GLASS FP, n = 71). The Kaplan-Meier method was used to estimate the wound healing rate. The Cox proportional hazard model was used to assess the association between baseline characteristics and wound healing. RESULTS: No patient underwent EVT for IP lesions. IP arterial anatomical characteristics did not show any significant difference between the low and high GLASS FP groups. The cumulative wound healing rate after EVT was significantly higher in the high GLASS FP group than in the low GLASS FP group (88% vs. 39% at 6 months; P < 0.001). Multivariate analysis revealed that low wound, ischemia, and foot infection (WIfI) clinical stage (stage 1 or 2) (hazard ratio [HR] 2.33; 95% confidence interval [CI] 1.32-4.17) and high GLASS FP (grade 3 or 4) (HR 5.18; 95% CI 1.99-13.51) were independent factors for wound healing. CONCLUSIONS: High GLASS FP grade was positively associated with wound healing after EVT only for FP lesions.

Predictors of delayed wound healing after simultaneous endovascular treatment and minor forefoot amputation for chronic limb-threatening ischemia with wound infection.

OBJECTIVES: To assess wound healing after simultaneous endovascular treatment (EVT) and minor forefoot amputation and identify the predictors of delayed wound healing in patients with chronic limb-threatening ischemia (CLTI) and bacterial infections of the wounds. METHODS: In this single-center retrospective cohort study, we evaluated 79 consecutive limbs with tissue loss from 73 CLTI patients who underwent simultaneous EVT and minor forefoot amputation between November 2017 and May 2020. To estimate the rate of wound healing after the simultaneous procedure, we used the Kaplan-Meier method. To assess the association between baseline characteristics and delayed wound healing, we used the Cox proportional hazard model. RESULTS: All patients who underwent the simultaneous procedure had ischemic wounds with bacterial infection. The rate of wound healing at 6 months reached 82%. The median time for wound healing was 76 days. According to multivariable analysis, Lisfranc/Chopart amputation (hazard ratio (HR) 2.46, 95% confidence interval (CI) 1.09-6.60), absence of above-the-knee (ATK) occlusive lesions (HR 1.89, 95% CI 1.04-3.45), and poor below-the-ankle (BTA) runoff (HR 1.77, 95% CI 1.01-3.11) were independent predictors of delayed wound healing. CONCLUSION: Lisfranc/Chopart amputation, absence of ATK occlusive lesions, and poor BTA runoff were independent predictors of delayed wound healing after simultaneous EVT and minor forefoot amputation in patients with CLTI and bacterial infections of the wound.

Impact of Antimicrobial-Resistant Bacterial and Polymicrobial Infection on Wound Healing After Minor Forefoot Amputation in Chronic Limb-Threatening Ischemia With Infection.

OBJECTIVES: This study aimed to evaluate the relationship between bacteriological findings and wound healing after minor amputation in the treatment of chronic limb-threatening ischemia (CLTI) with infection. METHODS: This single-center retrospective study analyzed 135 consecutive limbs with tissue loss and infection from 120 patients who underwent endovascular therapy (EVT) and minor forefoot amputation for CLTI with wound infection between November 2017 and August 2021. The Kaplan-Meier method was used to assess the rate of wound healing after the procedure. The Cox proportional-hazards model was used to examine the impact of bacteriological findings and baseline characteristics on wound healing. RESULTS: The wound healing rate at 6 months was 72.6%. In a multivariate analysis, in addition to hemodialysis (hazard ratio [HR]=1.73; p=0.009) and amputation above the metatarsophalangeal (MP) joint (HR=1.81; p=0.006), antimicrobial-resistant bacterial infection (HR=1.80, p=0.004) and polymicrobial infection (H=1.51; p=0.049) were predictors of delayed wound healing. CONCLUSION: Antimicrobial-resistant bacterial infection, polymicrobial infection, hemodialysis, and amputation above the MP joint were independent predictors of delayed wound healing after EVT and minor forefoot amputation in patients with CLTI and bacterial wound infection. CLINICAL IMPACT: In this single-center retrospective study, we analyzed 136 consecutive limbs with tissue loss and infection from 120 patients who underwent endovascular therapy and minor forefoot amputation for chronic limb-threatening ischemia (CLTI) with wound infection between November 2017 and August 2021. Our main findings were that antimicrobial-resistant bacterial infection, polymicrobial infection, hemodialysis, and amputation above the metatarsophalangeal joint were independent predictors of delayed wound healing after minor amputation. This is the first report of the association between bacteriological studies and wound healing in CLTI with infection, and will be of great help in the future clinical practice.

Successful Percutaneous Fogarty Thrombectomy for Subacute Lower Limb Ischemia Due to Resistant Thrombus in the Popliteal Artery.

BACKGROUND Subacute lower limb ischemia occurs more than 14 days and less than 3 months from symptom onset. Although endovascular procedures are the preferred treatment choice for a viable and not immediately threatened limb in patients with acute lower limb ischemia (<14 days), percutaneous catheter-directed thrombolysis, percutaneous mechanical thrombectomy, or percutaneous thromboaspiration are not recommended, and no treatment strategy has yet been established for nonacute lower limb ischemia (>14 days). A percutaneous Fogarty thrombectomy, an endovascular thrombus removal procedure with the use of a large-caliber sheath and a Fogarty balloon catheter, has recently been reported as a less invasive alternative to open surgery in patients with acute lower limb ischemia. In this report, we use this technique for a case of subacute lower limb ischemia caused by a resistant thrombus. CASE REPORT A 73-year-old man with a diagnosis of essential thrombocythemia presented with symptoms of right lower limb ischemia, which started about a month before. The diagnosis was subacute lower limb ischemia due to a resistant thrombus in the popliteal artery. First, we attempted percutaneous thromboaspiration and prolonged dilation with a large-caliber balloon catheter, but there were still severe residual stenoses with delayed blood flow. Although vascular scaffold implantation might have achieved complete revascularization, we avoided it because of a high probability of stent fracture in the popliteal artery. Thus, we performed a subsequent percutaneous Fogarty thrombectomy immediately after the conventional endovascular recanalization failed, achieving complete revascularization and next-day discharge without any complications. CONCLUSIONS A percutaneous Fogarty thrombectomy could be a new treatment option for subacute lower limb ischemia due to a resistant thrombus, which can be performed immediately after failure of the conventional endovascular recanalization.

A model for predicting the time of early symptomatic restenosis after infrapopliteal angioplasty in patients with critical limb ischemia.

The objective of this study is to develop a model for predicting the time of early symptomatic (delayed or nonhealing wound) restenosis after infrapopliteal angioplasty in patients with critical limb ischemia (CLI). This is a single-center retrospective cohort study evaluating 60 de novo infrapopliteal lesions of 38 limbs in 35 patients with CLI, who underwent successful endovascular treatment (EVT) from October 2016 to December 2018 and follow-up angiography within 3 months from the procedure. Outcome measures were binary restenosis at follow-up angiography and clinical outcome at 3 months. Patient/limb/lesion characteristics were compared between the restenosis and non-restenosis groups. Angiographic restenosis predictors were assessed to develop a model for predicting the time of restenosis using multinomial logistic regression. The restenosis rate at follow-up angiography (median time, 41 days [IQR 27-58 days]) was 38% (23/60). After adjustment for covariables, longer period between EVT and follow-up angiography and lower C-reactive protein (CRP) were the predictors of angiographic restenosis. We developed a model for predicting the time of early symptomatic restenosis with a probability of 70%: "Days = 200 - 2.1 age - 13 CTO + 3.3 CRP" (R2 = 0.81, RMSE = 0.27), e.g., 80 years old, CTO (+), CRP 4.4 mg/dl: 32.2 days. The predictive model including age, CTO, and CRP might allow estimation of the period for the angiographic restenosis development.

Successful Retrieval of a Stuck Guidewire by Guiding Catheter Lock Technique in Renal Artery Stenting.

INTRODUCTION: The guiding catheter lock technique is a therapeutic technique to increase backup force of the guiding catheter in coronary artery interventions. SURGICAL TECHNIQUE: A 71 year old man presented with rapidly declining kidney function resulting from bilateral renal artery stenosis. During the renal artery stenting procedure, the 0.014" guidewire became trapped at the stent's distal edge. Although attempts were made to advance a microcatheter and balloon catheter over the trapped guidewire, these failed because of insufficient pushability of the guiding catheter. Therefore, the guiding catheter lock technique was used with a second guiding catheter, and the guidewire was successfully retrieved. DISCUSSION: The guiding catheter lock technique facilitated strong pushability to allow for successful retrieval of a stuck guidewire during renal artery stenting.

Primary percutaneous coronary intervention without stenting using excimer laser and manual thrombectomy in STEMI with duodenal ulcer perforation: a case report.

BACKGROUND: ST-segment elevation myocardial infarction (STEMI) and peptic ulcer perforation are both medical emergencies that require urgent intervention. In case that these time-sensitive medical emergencies present concomitantly, it remains unclear which one should be treated first. CASE SUMMARY: An 85-year-old man with melaena, epigastric pain, and severe anaemia was transferred to our emergency department and diagnosed as having inferior STEMI based on electrocardiogram. Emergency coronary angiography (CAG) revealed severe stenosis with thrombus in the proximal right coronary artery. Immediate oesophagogastroduodenoscopy and abdominal computed tomography detected the presence of duodenal ulcer perforation. Primary percutaneous coronary intervention (PCI) without stenting using excimer laser coronary angioplasty and manual thrombectomy was performed under intravascular ultrasound (IVUS) guidance to avoid dual antiplatelet therapy (DAPT). After successful PCI, the perforated viscus was surgically repaired with a laparoscopic omental patch. On Day 7, endoscopic haemostasis treated the oozing of blood from the duodenal ulcer. On Day 21, follow-up CAG and IVUS showed residual stenosis with organized thrombus in the culprit lesion, in which a drug-coated stent was directly implanted. He was discharged with a favourable clinical course on Day 23. DISCUSSION: We judged that PCI should take precedence over the surgical repair of perforated duodenal ulcer in our case since STEMI was an immediate life-threatening compared to the perforated viscus which had no active exsanguination. Excimer laser coronary angioplasty with manual thrombectomy might be an adequate option to avoid stent deployment and subsequent DAPT in such complex scenarios.

Spontaneous Resolution of Residual Shunting in 2 Compromised Patients after Amplatzer Occlusion of Postinfarction Ventricular Septal Defects.

Ventricular septal defect (VSD) is a rare, potentially fatal complication of acute myocardial infarction. When surgical closure is contraindicated, transcatheter closure may be an alternative. Residual shunting after transcatheter closure of postinfarction VSDs has been reported; however, we found few cases of this in patients who also had severe heart failure or hemolysis. We report 2 closures of postinfarction VSDs with use of the Amplatzer Septal Occluder. Both elderly patients-one with severe heart failure, one with persistent hemolysis, and neither a surgical candidate-had high-velocity residual shunting through the occluders. We intensively managed the patients' conditions and used angiography and transthoracic echocardiography to record the gradual disappearance of each shunt over 4 months-the first such serial monitoring of which we are aware. We think that even substantial shunting in the presence of severe heart failure or hemolysis can eventually resolve spontaneously, assuming effective management of the concomitant medical conditions.

Utility of preprocedural multidetector computed tomography in alcohol septal ablation for hypertrophic obstructive cardiomyopathy.

Preprocedural computed tomography (CT) imaging appears to provide an advantage in localization of the appropriate septal branch targeted for alcohol septal ablation (ASA). The objective of this study was to compare the clinical backgrounds, procedural characteristics, and outcomes of patients who underwent ASA with preprocedural CT assessment against those without CT assessment. Thirty consecutive patients with obstructive hypertrophic cardiomyopathy who underwent ASA were retrospectively included. Patients who underwent preprocedural CT (CT-guided ASA group, n = 11) were compared with patients who underwent ASA without CT (traditional ASA group, n = 19). The CT-guided ASA group had a significantly lower number of approached target vessels (1 [interquartile range {IQR}, 1-2] vs. 2 [IQR, 2-3], P = 0.036) and non-ablated target vessels (0 [IQR, 0-1] vs. 1 [IQR, 0-2], P = 0.031) than the traditional ASA group. There were no differences between the two groups in total fluoroscopy time, the amount of delivered radiation dose, and the volume of contrast medium used during the procedures. There were also no differences between the two groups in procedural success rate and improvement of left ventricular outflow tract gradient and New York Heart Association functional class at 1 month follow-up. CT had a significant impact on the ASA procedure diminishing the number of target vessels, and could be a reliable assessment modality to build its procedural strategy.

Rotational Atherectomy Followed by Drug-Coated Balloon Dilation for Left Main In-Stent Restenosis in the Setting of Acute Coronary Syndrome Complicated with Right Coronary Chronic Total Occlusion.

An 83-year-old man presented with recurrent acute coronary syndrome (ACS) at the left main coronary artery (LMCA) complicated with ostial chronic total occlusion (CTO) in the right coronary artery (RCA) (RCA-CTO). At the first LMCA-ACS approximately 1 year earlier, he had undergone LMCA-crossover stenting with a biolimus-eluting stent in the presence of RCA-CTO. At the second LMCA-ACS, we angiographically confirmed severe in-stent restenosis in the distal LMCA, in addition to angled severe stenosis in the just proximal LCx, and performed primary PCI for the LMCA bifurcation lesion under intra-aortic balloon pumping support. Because of difficulty in crossing a guidewire through the just proximal LCx lesion, we first performed rotational atherectomy against the LMCA in-stent eccentric lesion. After successfully crossing the guidewire into the LCx, we added balloon dilation with kissing balloon inflation followed by alternate drug-coated balloon dilation. An eight-month follow-up coronary angiography revealed no further vessel narrowing in the LMCA bifurcation lesion.

Entrapped optical frequency domain imaging-guided rewiring and reconstruction of a deformed coronary stent.

A 54-year-old man appeared to have acute coronary syndrome with 2 subtotal occlusive culprit lesions in the RCA and in the LCx, and intermediate stenosis in the LAD. Approximately 2 weeks after the primary PCI, we performed elective PCI for the LAD lesion. We confirmed presence of thin-cap fibroatheroma at the culprit on OFDI and implanted an everolimus-eluting stent (EES); however, the OFDI catheter was entrapped in the EES, leading to a serious stent deformation. Under the guidance of the entrapped OFDI itself, we could recross another guidewire, successfully reconstruct the deformed stent, and retrieve the OFDI catheter.

Relationship Between Mean Blood Pressure at Admission and In-Hospital Outcome After Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction.

A J-shaped or U-shaped curve phenomenon might exist between systolic blood pressure (SBP) or pulse pressure (PP) at admission and in-hospital mortality in Japanese patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). However, data regarding a relationship between mean blood pressure (MBP) at admission and in-hospital outcome in AMI patients undergoing primary PCI are still lacking in Japan.A total of 1,413 primary PCI-treated AMI patients were classified into quintiles based on admission MBP (< 79 n = 283, 79-91 n = 285, 92-103 n = 285, 104-115 n = 279, and ≥ 116 mmHg n = 281). Patients with MBP < 79 mmHg had a significantly higher in-hospital mortality, while mortality was not significantly different among the other quintiles: 16.6% (< 79), 4.9% (79-91), 3.9% (92-103), 3.2% (104-115), and 5.0% (≥ 116 mmHg). On multivariate analysis, Killip class ≥ 3 at admission, LMT or multivessels as culprit lesions, admission MBP < 79 mmHg, and age were independent positive predictors of in-hospital mortality, whereas hypercholesterolemia and TIMI 3 flow before/after PCI were negative predictors, while the other MBP categories were not.These results suggest that admission MBP < 79 mmHg might be associated with in-hospital death, and the in-hospital prognostic effects of MBP, the steady component of blood pressure, at admission might be different from those of SBP or PP, the pulsatile component of blood pressure, at admission in Japanese AMI patients undergoing primary PCI.

Rotational Atherectomy Followed by Drug-Coated Balloon Dilation in Possible Coronary Sequelae of Kawasaki Disease.

Rotational atherectomy with/without low-pressure balloon dilation has been a mainstay of interventional treatment for stenosis due to the coronary sequelae of Kawasaki disease (KD). Here, we report a restenosis case of probable coronary sequelae of KD treated with rotational atherectomy with low-pressure 2.5-mm balloon dilation 6 months previously. Under the guidance of optical frequency domain imaging, we performed rotational atherectomy followed by 2.5-mm drug-coated balloon (DCB) dilation for an atherosclerotic restenosis at the inlet of a calcified aneurysm in the proximal left anterior descending coronary artery. Coronary angiography 6 months later showed no apparent progression of vessel narrowing, and we could defer repeat intervention. The present case suggests that rotational atherectomy followed by DCB dilation could be an alternative revascularization therapy of choice in coronary KD sequelae complicated with atherosclerosis.

Percutaneous coronary intervention for three vessels of chronic total occlusion complicated with huge left ventricular thrombus.

A 55-year-old woman with symptoms of heart failure appeared to have ischemic cardiomyopathy complicated with 3-vessel chronic total occlusion (CTO), severely deteriorated left ventricular (LV) function, and large LV thrombus. Because of high risk of surgical thrombectomy in addition to coronary artery bypass grafting surgery, we first confirmed significant reduction of LV thrombus and performed percutaneous coronary intervention against the 3-vessel CTO under preceding anticoagulation therapy with warfarin, aspirin, and clopidogrel. By means of antegrade/retrograde approach, we successfully implanted everolimus-eluting stents one by one, leading to complete revascularization, dramatically improved LV function, and disappearance of LV thrombus without post-procedural embolism.

Survivors of acute myocardial infarction at left main trunk undergoing primary percutaneous coronary intervention.

Acute myocardial infarction (AMI) at left main trunk (LMT) is a deteriorated condition with high in-hospital morbidity and mortality; however, detailed data regarding AMI patients with LMT as culprit lesion (LMT-AMI patients) undergoing primary percutaneous coronary intervention (PCI) has been still limited. Using the AMI-Kyoto Multi-Center Risk Study database, clinical background, angiographic findings and results of primary PCI were retrospectively compared between primary PCI-treated LMT-AMI patients without in-hospital death (survivors, n = 21) and those with in-hospital death (non-survivors, n = 19). The survivors had higher values of estimated glomerular filtration rate (eGFR) and systolic blood pressure at admission and lower prevalence of Killip grade 4 than the non-survivors. Pre-procedural thrombolysis in myocardial infarction (TIMI) flow grade ≥2 at the initial coronary angiography (CAG) and post-procedural TIMI flow grade 3 at the final CAG were more frequent in the survivors, compared with the non-survivors. In contrast, age and gender did not differ significantly between the two groups. On multivariate analysis, higher eGFR and Killip grade 4 at admission were found to be independent in-hospital prognostic factors in the LMT-AMI patients. Admission eGFR and Killip grade 4 are tightly associated with in-hospital prognosis in LMT-AMI patients undergoing primary PCI.

Clinical impact of thrombus aspiration during primary percutaneous coronary intervention in acute myocardial infarction with occluded culprit.

Data regarding clinical efficacy of thrombectomy in patients with acute myocardial infarction (AMI) have been still limited in Japan. Using the AMI-Kyoto Multi-Center Risk Study database, the clinical background characteristics, angiographic findings, primary percutaneous coronary intervention (PCI) results and in-hospital prognoses were retrospectively compared between AMI patients with totally occluded infarct-related artery (IRA) (TIMI flow grade 0) undergoing thrombus aspiration during primary PCI (with-aspiration patients, n = 568) and those without thrombus aspiration (without-aspiration patients, n = 266). The with-aspiration patients were more likely to have higher TIMI grade in the IRA immediately after primary PCI, and had a lower in-hospital mortality rate than the without-aspiration patients. According to a multivariate analysis, thrombectomy as well as stent usage was found to be independent predictor of final TIMI flow grade ≥2 in the IRA, and the final TIMI flow grade ≥2 in the IRA was found to be an independent factor for in-hospital survival. These results suggest that among real-world, unselected Japanese AMI patients with totally occluded IRA on initial coronary angiography, thrombus aspiration is an effective adjunctive therapy during primary PCI to improve final epicardial coronary flow in the IRA, which might lead to better in-hospital prognosis.