Safety and efficacy of an endovascular-first approach to acute limb ischemia

Direct puncture versus contralateral femoral artery approach for catheter-directed thrombolysis of occluded infra-inguinal arterial bypass grafts

AIM

To compare the safety, effectiveness, and clinical outcome of percutaneous direct puncture approach versus contralateral femoral native vessel approach for catheter-directed thrombolysis of occluded infra-inguinal bypass grafts.

MATERIALS AND METHODS

A retrospective analysis was performed comprising a cohort of patients who underwent catheter-directed thrombolysis procedures of occluded infra-inguinal bypass grafts between January 2013 and January 2022, with a follow-up period until June 2022. This included 55 procedures via the native vessel approach and 18 procedures via the direct puncture approach. Primary outcomes were technical success and procedural safety; secondary outcomes included re-intervention rate, limb salvage, and mortality as assessed by log-rank testing and Kaplan-Meier curves.

RESULTS

There were no differences between the two groups with regard to patient demographics, except for the number of previous vascular procedures (n=6.83 ± 3.07 direct approach versus n=4.96 ± 2.79 native vessel approach, p=0.025). Thrombolysis was comparably successful in both groups (n=13/18; 72% direct approach versus n=42/55; 76%, p=0.723). There were no differences in the duration of thrombolysis administration. The rate of adverse events was slightly lower in the direct approach group, but without significance (p=0.092). There were no adverse events related to the puncture site in the direct approach group. No differences were found between the time-to-event values for re-occlusion, re-intervention, amputation, or mortality respectively (p=0.662; p=0.520; p=0.816; p=0.462).

CONCLUSION

The direct puncture approach seems to be a safe and efficient approach for catheter-directed thrombolysis procedures in infra-inguinal occluded bypass grafts, with clinical outcomes comparable to the native vessel approach.

Outcomes After Open Surgical, Hybrid, and Endovascular Revascularization for Acute Limb Ischemia

PURPOSE

To report the performance of surgical treatment (ST), hybrid treatment (HT), and endovascular treatment (ET) for patients with acute limb ischemia (ALI).

METHODS

This is a retrospective, comparative study of all consecutive patients with ALI treated in 2 tertiary centers between April 2010 and April 2020. Amputation and/or death (amputation-free survival; AFS) was the primary composite endpoint. Mortality, major amputation, and reintervention during follow-up were additionally analyzed. Proportional hazards modeling was used to identify confounders, results are presented as hazard ratio (HR) and 95% confidence intervals (CIs).

RESULTS

In total, 395 patients (mean age=71.1±13.6 years; 51.1% female) were treated during the study period. Surgical treatment was preferred in 150 patients (38%), while 98 were treated by HT (24.8%) and 147 by ET (37.2%). Rutherford class IIa was the most common clinical presentation in the ET group (50.3%), whereas Rutherford IIb was most common in the ST (54%) and HT (48%) groups (p<0.001). Significantly, more patients presented with a de novo lesion in the ST and HT groups (79.3% and 64.3%, respectively) compared with ET (53.7%; p<0.001). Median follow-up was 20 months (range=0-111 months). In the multivariate analysis, ET showed significantly better AFS during follow-up compared with ST (HR=1.89, 95% CI=1.2-2.9, p<0.001) and HT (HR=1.73, 95% CI=1.1-3.1, p<0.001). Mortality during follow-up was also significantly lower after ET compared with ST (HR=2.21, 95% CI=1.31-3.74, p=0.003) and HT (HR=2.04, 95% CI=1.17-3.56, p=0.012). Endovascular treatment was associated with lower amputation rate compared with ST (HR=2.27, 95% CI=1.19-4.35, p=0.013) but was comparable with HT (HR=2.00, 95% CI=0.98-4.06, p=0.055). Reintervention rates did not differ significantly between the groups (ET vs ST: HR=1.52, 95% CI=0.99-2.31, p=0.053; ET vs HT: HR=1.3, 95% CI=0.81-2.07, p=0.27).

CONCLUSION

Endovascular treatment for ALI was associated with improved AFS and comparable reintervention rates compared with open surgical and hybrid therapy.

CLINICAL IMPACT

Treatment of acute lower limb ischemia remains a challenge for clinicians with high morbidity and mortality rates. Endovascular revascularization is considered first line treatment for many and hybrid treatments are becoming more common, however data is limited to either old trials, small series or with short follow-up. We present herein our 10-year experience with all available devices and techniques for open surgical, endovascular and hybrid acute limb ischemia treatments and compare their outcomes.

Outcomes of Surgical Revascularization for Acute Limb Ischemia in COVID-19 Patients Comparing to Noninfected Cohort: A Single-Center Observational Prospective Study

BACKGROUND

The purpose of the study was to compare the clinical presentation, management, and outcomes of surgical revascularization for acute limb ischemia (ALI) in 2 groups of patients-with and without SARS-CoV-2 infection.

METHODS

During the 2 years (01.01.2020-31.12.2021) all consecutive patients diagnosed with ALI and treated with urgent revascularization were prospectively enrolled. Based on the results of polymerase chain reaction swab for SARS-CoV-2 infection patients were allocated to group A-infected or group B-noninfected. Demographic characteristics, clinical, imaging, laboratory data, and details of treatment were collected prospectively. The composite endpoint of major amputation and/or death at 30 days after surgery was defined as main study outcome. The postoperative ankle-brachial index value, reinterventions, complications, and length of hospital stay were considered as secondary outcomes.

RESULTS

Overall, 130 patients (139 limbs with ALI) were analyzed-21 patients (23 limbs) in group A and 109 patients (116 limbs) in group B. The anatomical site of arterial occlusion, duration, and severity of ischemia did not differ significantly between the groups. Patients with COVID-19 had significantly shorter time from ALI onset till administration of the first dose of anticoagulant: 8 (2.5-24) hr vs. 15.7 (6-72) hr in group B, P = 0.02. Vascular imaging was performed before intervention only in 5 (23.8%) infected patients compared to 78 (71.5%) patients in group B, P < 0.001. The main outcome was registered in 38 (29.2%) patients, significantly more frequent in infected cohort: 12 (57.1%) patients in group A versus 26 (23.8%) in group B, P = 0.003. Difference was preponderantly caused by high mortality in group A-9 (42.8%) patients, compared to 17 (15.5%) patients in group B, P = 0.01. The difference in the rate of limb loss was not statistically significant: 4 (17.3%) limbs were amputated in COVID-19 patients and 12 (10.3%) limbs-in noninfected patients (P = 0.3). Combination of ALI and COVID-19 resulted in increased 30-day mortality-risk ratio (RR) 2.7 (95% confidence interval [CI]: 1.42-5.31), P = 0.002, but did not lead to significantly higher amputation rate-RR 1.6 (95% CI: 0.59-4.75), P = 0.32. In group A initial admission of the patient in the intensive care unit was an independent risk factor for amputation/death. Excepting systemic complications which were more frequently registered among COVID-19 patients: 7 (33%) cases vs. 14 (12.8%) in group B, P = 0.04; no differences in other secondary outcomes were observed between the groups.

CONCLUSIONS

Study demonstrates the significant negative impact of COVID-19 upon the 30-day amputation-free survival in patients undergoing urgent surgical revascularization for ALI. The difference in outcome is influenced by higher rate of mortality among infected patients, rather than by the rate of limb loss. Severity of COVID-19, namely requirement of intensive care, mostly determines the outcome of ALI treatment.

Repeated acute lower limb ischemia due to complete occlusion of an artificial vessel graft: A case report

Key Clinical Message

In cases involving an occluded artificial blood vessel graft, thrombosis of the vessel can cause lower limb ischemia. When thromboembolism develops, it is essential to rule out the complete occlusion of an artificial blood vessel graft as the cause.

Abstract

A 60-year-old woman with bilateral superficial femoral artery occlusion underwent femoral-popliteal bypass surgery. Six months later, left vascular prosthesis occlusion occurred; 1.5 years later, an occlusive embolus developed in the deep femoral artery. The proximal prosthesis aspect was detached from the native vessel. The limb was salvaged with bypass surgery.

Impact of Revascularization Technique on the Outcomes of Peripheral Graft Revision Procedures

BACKGROUND

The acute occlusion of a peripheral bypass graft leads to acute limb ischemia (ALI) and threatens the viability of the limb if left untreated. The aim of the present study was to analyze the results of surgical and hybrid revascularization techniques for patients with ALI due to peripheral graft occlusions.

METHODS

A retrospective analysis of 102 patients undergoing treatment for ALI due to peripheral graft occlusion between 2002 and 2021 was carried out at a tertiary vascular center. Procedures were classified as surgical when only surgical techniques were used and as hybrid when surgical procedures were combined with endovascular techniques such as balloon or stent angioplasty or thrombolysis. Endpoints were primary and secondary patency and amputation-free survival after 1 and 3 years.

RESULTS

Of all patients, 67 met the inclusion criteria, 41 were treated surgically and 26 by hybrid procedures. There were no significant differences in the 30-day patency rate, 30-day amputation rate, and 30-day mortality. The 1- and 3-year primary patency rates were 41.4% and 29.2% overall, respectively; 45% and 32.1% in the surgical group, respectively; and 33.2% and 26.6% in the hybrid group, respectively. The 1- and 3-year secondary patency rates were 54.1% and 35.8% overall, respectively; 52.5% and 34.2% in the surgical group, respectively; and 54.4% and 43.5% in the hybrid group, respectively. The 1- and 3-year amputation-free survival rates were 67.5% and 59.2%, overall, respectively; 67.3% and 67.3% in the surgical group, respectively; and 68.5% and 48.2% in the hybrid group, respectively. There were no significant differences between the surgical and the hybrid groups.

CONCLUSIONS

The results of surgical and hybrid procedures after bypass thrombectomy for ALI to eliminate the cause of infrainguinal bypass occlusion are comparable with good midterm results in terms of amputation-free survival. New endovascular techniques and devices need to be established in comparison to the results of these proven surgical revascularization methods.

Young patients without prior vascular disease are at increased risk of limb loss and reintervention after acute limb ischemia

BACKGROUND

The objective of the present study was to categorize the presentation and treatment of acute limb ischemia (ALI) in young patients and compare the adverse outcomes after revascularization compared with that of older patients.

METHODS

All the patients who had presented to a multi-institution healthcare system with ALI from 2016 to 2020 were identified. The presenting features, operative details, and outcomes were included in the present analysis. Patients with existing peripheral arterial disease (acute on chronic) were analyzed separately from those without (de novo thrombosis or embolus). Within these groups, younger patients (age, ≤50 years) were compared with older patients (age, >50 years). The 3-month major adverse limb event-free survival was the primary outcome.

RESULTS

A total of 232 patients (age, 60 ± 16 years; 44% female sex, 87% white race) were included in the analysis. Of the 232 patients, 119 were in the acute on chronic cohort and 113 were in the de novo thrombosis/embolism cohort. Age did not affect the overall outcomes (P = .45) or the outcomes for the acute on chronic group (P = .17). However, in the de novo thrombosis/embolism cohort, patients aged ≤50 years had worse major adverse limb event-free survival compared with patients aged >50 years (hazard ratio, 2.47; 95% confidence interval, 1.08-5.68; P = .03) after adjustment for Rutherford class, interval from presentation to the operating room, and smoking status. In the de novo thrombosis/embolism group, the operative approach was similar across the age groups (endovascular, 12% vs 14%; open, 48% vs 41%; hybrid, 41% vs 45%; P = .78). In the younger patients, embolism was more likely from a proximal arterial source (71%). In contrast, in the older patients, the source of embolism was more often a cardiac source (86%). The rates of hypercoagulable disease were equal across the age groups (10% vs 10%; P = .95). The In-hospital mortality was 3% overall (acute on chronic, 5%; de novo, 3%).

CONCLUSIONS

Despite advances in interventional options, for patients with ALI due to de novo thrombosis or embolus, younger age was associated with worse short-term limb-related outcomes.

Balloon-Assisted Endovascular Thrombectomy for Tibial Thromboembolism

We present a novel approach to endovascular thrombectomy using the Penumbra Indigo® Aspiration System with balloon assistance for a thromboembolic occlusion to the tibioperoneal trunk and tibial arteries causing acute limb ischemia. This technique allows for effective suction thrombectomy of distal vessels into a shorter, large-diameter aspiration catheter, thereby overcoming the limitations of the longer but smaller aspiration catheters.