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BACKGROUND: Chronic limb-threatening ischemia (CLTI) is the end-stage of peripheral arterial disease (PAD) posing a high risk for limb loss and mortality. This study aims to evaluate and list possible predictors of major adverse limb events (MALEs) in CLTI patients with tissue loss. METHODS: This retrospective study included all Rutherford-Becker stage 5 or 6 patients who required foot debridement and revascularization in our department from January 2016 to December 2018. The limbs were classified according to the TASC II, GLASS and WiFI grading systems. The primary composite outcome was MALEs at 2 years. The secondary outcomes included all-cause mortality, primary patency, freedom from reintervention, and major amputation. Kaplan-Meier estimates were used to determine the event rates, and Cox proportional hazards model with the index MALE as a time-dependent covariate was used to search for MALEs predictors. RESULTS: Of 241 included patients, 19 underwent open surgeries (7.9 %) 207 had endovascular interventions (85.9 %) and 15 required a hybrid approach (6.2 %). On univariate analysis, patients who experienced MALEs (n = 111) more often required hemodialysis (25 vs 15; p = .02), presented with more complex lesions (TASC D on femoropopliteal (p = .05) or below the knee (BTK) arteries (p = .006) with increasing infra-inguinal GLASS Stage (p < .0001)), a history of index limb open (p = .009) or endovascular (p = .049) revascularization, an occluded tibial artery (p = .002 for the posterior tibial and p = .052 for the anterior tibial), or a "desert foot" (p = .02). The CRP level was also higher at admission (p = .001). Technical success of BTK revascularization significantly reduced MALEs (p < .0001) along with the number of patent BTK vessels (p = .0007). Independent predictors of MALEs included hemodialysis (HR = 2.00; 95%CI: 1.14 to 3.39), pulsatile arterial pressure (HR = 1.01; 95%CI: 1.00 to 1.03) and the infra-inguinal GLASS Stage (HR = 2.50; 95%CI: 1.17 to 5.82). We could not correlate our results with the WiFI scores for amputation risk and revascularization benefit. CONCLUSION: For patients with CLTI at the stage of trophic disorders, with or without a history of index limb revascularization, the GLASS successfully predicted MALEs. Hemodialysis and high pulsatile arterial pressure increased the risk of MALEs. The WiFI score did not demonstrate its interest in this subgroup of patients.
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INTRODUCTION: Alarming outcomes have been reported following infected endovascular aortic aneurysm repair (EVAR) device explantation. Infected fenestrated EVAR (FEVAR) exposes patients to even worse procedural risks. REPORT: A 67 year old man with a prior history of FEVAR presented with impaired general condition, abdominal and back pain, and increased C reactive protein. Computed tomography angiography revealed a collection around the aortic graft bifurcation and 18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed increased FDG uptake at this level, confirmed by labelled white blood cells, all favouring graft infection. A thoracophrenolumbotomy was performed and revealed an aorto-enteric fistula which was treated by small bowel resection. The left renal artery was transected at the distal end of the bridging stent and a thoracorenal bypass was performed. The thoracic aorta was cross clamped above the coeliac trunk for complete graft excision. Meanwhile, the right kidney was perfused with 4°C Ringer lactate solution. In situ reconstruction was accomplished with a bifurcated antimicrobial graft sutured below the superior mesenteric artery with re-implantation of the right renal artery. The patient was left with a laparostomy for definitive abdominal closure, restoration of the digestive tract, and omental wrap 72 hours later. Broad spectrum antibiotic therapy was initiated peri-operatively and reduced to sulfamethoxazole/trimethoprim for a total duration of six weeks after one sample was positive for Moraxella osloensis. Eleven months later, the patient was free from re-infection, with no fever or inflammatory syndrome. DISCUSSION: Total explantation of stent grafts with tissue debridement and post-operative antibiotic therapy is the gold standard when dealing with infected EVAR. As with type IV thoraco-abdominal aneurysm open repair, FEVAR device explantation requires additional protective measures to prevent visceral ischaemia and renal impairment. In agreement with the European Society for Vascular Surgery guidelines, such patients should be referred to dedicated vascular centres with expertise in surgical repair, anaesthetics, and post-operative intensive care.
