Minor amputation after revascularization in chronic limb-threatening ischemia: What is the optimal timing?

OBJECTIVES: Patients with chronic limb-threatening ischemia (CLTI) have a high risk of lower limb amputation and loss of walking independence. Minor amputations play a key role in ensuring walking independence and they represent a challenge in terms of timing and level for vascular surgeons. A major cause of re-amputation is a defect in wound healing and a possible predictor of re-amputation for non-healing wounds could be the incorrect timing of minor amputation after revascularization. The lack of evidence in the literature leads to a wide variability of choices in clinical practice. The purpose of this study was to try to find the optimal timing analysing the risk of re-amputation in CLTI patients who have undergone successful revascularization and minor amputation focussing on timing of minor amputation. METHODS: We conducted a single centre retrospective analysis on a cohort of 151 patients consecutively admitted to our hospital for CLTI (Rutherford 5) between January 2014 and April 2022. All the enrolled patients underwent successful revascularization of lower limbs and a minor amputation for dry acral necrosis. The characteristics of the patients and the revascularization procedures were collected and analysed. Patients were divided into two groups based on the timing of minor amputation performed before (group 1) or after the day (group 2) that best predicts the risk of re-amputation according to a Receiver Operating Characteristic (ROC) curve analysis. The primary outcome of this study was the risk of re-amputation during the first 60 days of follow-up after a primary minor amputation, with revascularization still effective. The impact of the timing of minor amputation after revascularization, the type of revascularization and the presence of risk factors known to prolong the wound healing process were evaluated in a uni- and multi-variable logistic regression model. RESULTS: Systemic hypertension, and type of revascularization (i.e. open vs endovascular) were independent predictors of the risk of re-amputation at 60 days (HR 4.26, 95% CI 1.30-14.04, p = .017 and HR 2.35, 95% CI 1.16-4.78, p = .018, respectively). Moreover, time ≤14 days between revascularization and first amputation was associate with a clear, albeit not statistically significant, trend toward increased risk of re-amputation (HR 2.09, 95% CI 0.97-4.51, p = .06). CONCLUSIONS: In a cohort of patients who underwent a successful revascularization for CLTI and a minor amputation for dry gangrene in the first 14 days after revascularization, a higher -although not significant-risk of re-amputation was reported. In this cohort of patients, a delayed demolitive procedure should be considered to allow better tissue perfusion and to reduce the risk of re-amputation.

Refractory Chylothorax Secondary to Sizeable Azygos Vein Hemangioma: Tailored Multimodal Treatment of a Challenging Case Report.

BACKGROUND: Mediastinal hemangiomas are rare, and their etiology remains unclear. Most patients affected have no pathognomonic clinical symptoms, and the diagnosis is often incidental. Due to the paucity of the available literature regarding the management of this disease, the choice and timing of treatment remains controversial. CASE PRESENTATION: Herein, we report the case of a hemangioma of the azygos vein arch in a 66-year-old woman who presented with dyspnea, chest discomfort, dysphagia, and weight loss. A simultaneous right chylothorax refractory to conservative management was found. A CT-guided biopsy of the mass was performed, and it confirmed the vascular nature of the lesion. Therefore, the patient underwent an angiography followed by endo-vascular embolization. Three days later, thoracoscopic surgical resection of the mass and the repair of the chyle leakage were performed safely. The patient was discharged uneventfully on postoperative day seven, with complete resolution of all the presenting symptoms. CONCLUSIONS: Treatment of symptomatic mediastinal hemangiomas could be mandatory, but a thorough multidisciplinary approach to these rare malformations is essential. Despite the risk of intraoperative bleeding, selective endovascular embolization followed by thoracoscopic surgery allowed for a complete and safe resection with a good outcome.

Hybrid Clampless Anastomosis in Antegrade Aorto-Superior Mesenteric Artery Bypass.

BACKGROUND: Bypass surgery in severe aorto-iliac calcifications is a complex procedure. Aortic clamping can be highly risky and endovascular approach can be unsuccessful. We report our experience describing three cases of chronic mesenteric ischemia. In all three cases the preoperative computed tomography angiography revealed an ostial occlusion of the celiac trunk and of the superior mesenteric artery (SMA), a coral reef abdominal aorta, and severe calcification of the iliac arteries. An antegrade aorto-mesenteric bypass using a hybrid clampless anastomosis on the supraceliac aorta was performed. RESULTS: The procedures were performed via laparotomy. We carried out the exposure of the anterior supraceliac aorta limited to the zone without major calcifications; then we performed a side-to-end media-adventitial anastomosis between the supraceliac aorta and a Dacron graft 7 mm without any arteriotomy or clamping. The proximal graft and the aortic anastomosis site were punctured using a 18 G needle. An introducer was then positioned over a wire through the prosthetic graft and pushed into the aorta. Balloon expandable covered stenting to open and stabilize the anastomosis site was performed. Finally, the graft was tunneled to the SMA, and an end-to-side anastomosis was performed. The postoperative courses were uneventful, and the patients were promptly discharged. The follow-up, which in the first case is 4 years, showed the complete patency of the graft in each of the cases treated. CONCLUSIONS: The hybrid clampless anastomosis appears to be safe and useful in cases of severe aortic calcification.

Spontaneous Isolated Dissection of Iliac Artery Treated with Endovascular Repair: A Case Report.

Spontaneous isolated dissection of the iliac artery (SID-IA) is a rare pathologic condition. The predisposing factors and best treatment strategies are still being debated. We present the case of a 59-year-old male with acute right lower limb ischemia characterized by the sudden occurrence of rest pain, hypoesthesia, and paresis. Angiography showed SID-IA extending down to the femoral bifurcation. The patient had no risk factors for SID-IA; however, he survived an electrocution and had arterial hypertension at admission. Endovascular revascularization was successfully performed, with complete restoration of limb blood flow and remission of symptoms. Follow-up ultrasonography at 1 year confirmed stent patency and absence of clinical symptoms. Endovascular stenting is a good therapeutic option for symptomatic SID-IA without rupture.