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Minici R, Ammendola M, Talarico M, Luposella M, Minici M, Ciranni S, Guzzardi G, Laganà D. Endovascular recanalization of chronic total occlusions of the native superficial femoral artery after failed femoropopliteal bypass in patients with critical limb ischemia. CVIR Endovasc 2021; 4:68. [PMID: 34491477 PMCID: PMC8423883 DOI: 10.1186/s42155-021-00256-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/23/2021] [Indexed: 12/24/2022] Open
Abstract
Background Femoropopliteal bypass occlusions are a significant issue in patients with critical limb ischemia and chronic total occlusion of the native superficial femoral artery, which challenges vascular surgeons and interventional radiologists. Performing a secondary femoropopliteal bypass is still considered the standard of care, although it is associated with a higher complication rate and lower patency rate in comparison with primary bypass. Over the past few years, angioplasty has been commonly used, with the development in endovascular technologies, to treat chronic total occlusions of the native superficial femoral artery, with a good technical success rate and clinical prognosis. The purpose of the study is to assess the outcome of endovascular recanalization of chronic total occlusions of the native superficial femoral artery, in patients unfit for surgery with critical limb ischemia after failed femoropopliteal bypass. Results A total of 54 patients were treated. 77.8 % of the conduits were PTFE grafts; the remainder were single-segment great saphenous veins. The most common clinical presentation was rest pain. Technical success was achieved in 51 (94.4 %) of 54 limbs. Angiographically, 77.8 % of the lesions were TASC II category D, while 22.2 % were TASC II category C. The average length of the native SFA lesions was 26.8 cm. Clinical success, with improved Rutherford classification staging, followed each case of technical success. The median follow-up value was 5.75 years (IQR, 1.5–7). By Kaplan-Meier survival analysis, primary patency rates were 61 % (± 0.07 SE) at 1 year and 46 % (± 0.07 SE) at 5 years. Secondary patency rates were 93 % (± 0.04 SE) at 1 year and 61 % (± 0.07 SE) at 5 years. Limb salvage rates were 94 % (± 0.03 SE) at 1 year and 88 % (± 0.05 SE) at 5 years. Conclusions The endovascular recanalization of chronic total occlusions (CTO) of the native superficial femoral artery (SFA) after a failed femoropopliteal bypass is a safe and effective therapeutic option in patients unfit for surgery with critical limb ischemia.
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Affiliation(s)
- Roberto Minici
- Radiology Division, Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, University Hospital Mater Domini, Viale Europa, 88100, Catanzaro, Italy.
| | - Michele Ammendola
- Digestive Surgery Unit, Science of Health Department, Magna Graecia University, Catanzaro, Italy
| | - Marisa Talarico
- Cardiology Division, Giovanni Paolo II Hospital, Lamezia Terme, Italy
| | - Maria Luposella
- Cardiovascular Disease Unit, San Giovanni di Dio Hospital, Crotone, Italy
| | - Marco Minici
- Institute for high performance computing and networking (ICAR), National Research Council (Cnr), Rende, Italy
| | - Salvatore Ciranni
- Vascular Surgery Division, University Hospital Mater Domini, Catanzaro, Italy
| | - Giuseppe Guzzardi
- Radiology Division, Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
| | - Domenico Laganà
- Radiology Division, Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, University Hospital Mater Domini, Viale Europa, 88100, Catanzaro, Italy
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Migliara B, Cappellari TF, Mirandola M, Griso A, Kolasa K, Zah V, Nicoletti C, Lino M. Treatment of bypass failure in patients with chronic limb threatening ischemia – open surgery vs. percutaneous mechanical thrombectomy. VASA 2020; 49:395-402. [DOI: 10.1024/0301-1526/a000883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Summary: Background: Lower limb bypass occlusion in patients with chronic limb threating ischemia remains a challenge. We can choose between different treatment options: open surgery, local thrombolysis, thrombectomy/atherectomy devices. In this pilot study, we compare clinical outcomes and treatment costs between open surgery (OS) and percutaneous mechanical thrombectomy (pMTH). Patients and methods: This pilot study represents a retrospective analysis of hospital data of 48 occluded bypasses admitted from 2013 to 2018. Only patients presenting with severe ischemia and recrudescence of symptoms (Rutherford 4–6) were included in the current analysis. Two cohorts of patients were analysed: patients who underwent OS and patients that underwent pMTH. Primary clinical outcomes were one-year cumulative patency and limb salvage rates. Total cost was calculated as a sum of intra- and post-operative costs. To weigh clinical benefits against the economic consequences of OS versus pMTH a cost-effectiveness framework was adopted. Results: We analysed a series of 48 occluded bypasses 17 treated with open surgery and 31 with pMTH. Procedural success was 100% in both groups. When comparing one-year death rates ( p-value = .22) and re-occlusion rates ( p-value = .43), no statistically significant differences were observed between the two cohorts. Mean patency duration in the surgery cohort was significantly shorter ( p-value < .05). Primary patency (OS 41.2% vs. pMTH 48.4%) and limb salvage rate (OS 88.2% vs. pMTH 90.3%) at one year are similar in both groups. The total cost of surgery was substantially higher (OS 10,159€ vs. pMTH 8,401€) Conclusions: This pilot study, although limited to 48 occluded bypasses, demonstrates that endovascular treatment with pMTH is less invasive, less time consuming and less expensive, and produces greater health benefits than traditional OS.
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Affiliation(s)
- Bruno Migliara
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
| | | | - Mattia Mirandola
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Andrea Griso
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Katarzyna Kolasa
- Economics and Healthcare Management Division, Kozminski University, Poland
| | | | - Cristian Nicoletti
- Diabetic Foot Unit, Department of Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
| | - Marcello Lino
- Vascular and Endovascular Unit, Department of Surgery, Pederzoli Hospital, Peschiera del Garda, Italy
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Abstract
Background: Endovascular therapy for acute lower limb ischemia (ALLI) has developed and
demonstrated safety and efficacy. The purpose of this study was to assess
clinical outcomes in patients treated for ALLI with conventional
endovascular or surgical revascularization. Method: This study was a retrospective single-center review. Consecutive patients
with ALLI treated with conventional endovascular revascularization (ER)
without thrombolytic agent or surgical revascularization (SR) between 2008
and 2014 were investigated. The 1 year and 3 year amputation rate and
mortality rate were assessed by time-to-event methods, including
Kaplan–Meier estimation. Result: A total of 64 limbs in 62 patients with ALLI due to thromboembolism or
thrombosis of a native artery, bypass graft, or previous stented vessel were
included. The majority of limbs (90.9%) presented with Rutherford clinical
categories 1 to 2 ischemia. Technical success rate was 95.5% in ER and 92.9%
in SR group (p = 0.547). Overall amputation rates were 9.1%
in ER versus 9.5% in SR after 1 year
(p = 0.971) and 9.1% in ER versus 11.9% in
SR after 3 year (p = 0.742). Overall mortality rates were
15% in ER versus 7.1% in SR after 1 year
(p = 0.491) and 15% in ER versus 11.2%
in SR after 3 year (p = 0.878). Conclusion: Endovascular or surgical revascularization of ALLI resulted in comparable
outcomes in limb salvage and mortality rate at 1 year and 3 year.
Conventional endovascular therapy without thrombolytic agent such as
stenting, balloon angioplasty, or catheter-directed thrombosuction may be
considered as a treatment option for ALLI.
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Affiliation(s)
- Keisuke Fukuda
- Department of Cardiology, Kishiwada Tokushukai Hospital, 4-27-1 Kamori-cho, Kishiwada City, Osaka, Japan 596-8522
| | - Yoshiaki Yokoi
- Department of Cardiology, Kishiwada Tokushukai Hospital, Kishiwada City, Osaka, Japan
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What Is the Secondary Patency of Thrombosed Bypasses of the Lower Limbs Cleared by Fibrinolysis In Situ? Ann Vasc Surg 2019; 61:48-54. [PMID: 31075461 DOI: 10.1016/j.avsg.2019.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 02/12/2019] [Accepted: 02/14/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND In case of acute thrombosis, lower limb bypasses can, in certain cases, be cleared by local intra-arterial fibrinolysis (LIF). The aim of this study is to evaluate the secondary patency of thrombosed bypasses after fibrinolysis. METHODS This retrospective study includes all patients hospitalized for thrombosed bypasses of the lower limbs that were treated with in situ fibrinolysis using urokinase, between 2004 and 2013, in 2 French university hospital centers. Fibrinolysis was indicated in case of recent thrombosis (<3 weeks) provoking acute limb ischemia without sensory-motor deficit and in the absence of general contraindications. The secondary patency of the grafts was defined as the time after fibrinolysis without a new thrombotic event. RESULTS There were 207 patients, hospitalized for recent thrombosis of 244 bypasses. The LIF was efficient in 74% of the cases (n = 180). Secondary patency of these bypasses was 54.2% and 32.4% overall, 68.3% and 50.3% for the suprainguinal bypasses, and 48.3% and 21.5% for the infrainguinal bypasses at 1 and 5 years, respectively. There is a significant difference (P = 0.002) regarding the permeability of the suprainguinal and infrainguinal bypasses. The survival rate was 75% (±6.4%) at 5 years and the limb salvage rate was 89% (±3.3%), 78.2% (±5.1%), and 75% (±5.8%) at 1, 3, and 5 years, respectively. The only independent factor influencing the secondary patency of infrainguinal bypasses that was significant in a multivariate analysis was the infragenicular localization of the distal anastomosis (P = 0.023). CONCLUSIONS LIF is an effective approach that often allows the identification of the underlying cause, permitting elective adjunctive treatment of the underlying cause. Although LIF is at least as effective as its therapeutic alternatives described in the literature, the secondary patency of the bypasses remains modest and encourages close monitoring, particularly in patients with an infragenicular bypass.
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Vanheer R, Laenen A, Bonne L, Cornelissen S, Verhamme P, Houthoofd S, Fourneau I, Maleux G. A comprehensive report of long-term outcomes after catheter-directed thrombolysis for occluded infrainguinal bypass grafts. J Vasc Surg 2019; 70:1205-1216. [PMID: 30922746 DOI: 10.1016/j.jvs.2018.12.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 12/12/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The objective of this study was to assess the technical and short- and long-term clinical outcomes of catheter-directed thrombolysis (CDT) with urokinase for occluded infrainguinal bypass grafts. In addition, factors associated with technical success and amputation-free survival were assessed. METHODS A retrospective analysis of a cohort of patients treated with catheter-directed urokinase-based thrombolysis for occluded infrainguinal bypass grafts was conducted between January 2000 and December 2015. Demographics, procedural data, and short- and long-term outcome data, including patency rates of the bypasses, limb salvage, and overall survival, were collected. Statistical models for clustered data were applied to assess predictive factors. RESULTS In 177 patients, 251 CDTs were performed on 204 bypasses. In 209 procedures (83.3%), the occluded bypass was reopened; clinical disappearance of ischemic symptoms occurred after 157 procedures (62.6%). Premature cessation of thrombolysis occurred in 33 procedures (13.2%), and periprocedural and postprocedural complications were noted in 91 patients (36.3%). Factors associated with long-term limb salvage are fewer vascular interventions before CDT (P = .0003), higher number of patent outflow vessels before start of CDT (P < .0001), and higher number of patent outflow vessels after CDT (P < .0001). The 1- and 5-year patency rates of bypasses after successful CDT were 64.6% and 48.9%; amputation-free survival after 1 year, 5 years, and 7 years was 81.5%, 71.3%, and 70.5%, respectively. CONCLUSIONS Clinical success after CDT was observed in 62% of procedures with an associated complication rate of 36%. Patent outflow vessels before and after CDT are factors associated with long-term limb salvage. Amputation-free survival after 5 years is 71.3%.
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Affiliation(s)
- Ruben Vanheer
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium; Department of Imaging and Pathology, Catholic University of Leuven, Leuven, Belgium
| | - Annouschka Laenen
- Interuniversity Centre for Biostatistics and Statistical Bioinformatics, Catholic University of Leuven, Leuven, Belgium; Interuniversity Centre for Biostatistics and Statistical Bioinformatics, University Hasselt, Hasselt, Belgium
| | - Lawrence Bonne
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium; Department of Imaging and Pathology, Catholic University of Leuven, Leuven, Belgium
| | - Sandra Cornelissen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium; Department of Imaging and Pathology, Catholic University of Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiology and Vascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Sabrina Houthoofd
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Inge Fourneau
- Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Geert Maleux
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium; Department of Imaging and Pathology, Catholic University of Leuven, Leuven, Belgium.
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Hage AN, McDevitt JL, Chick JFB, Vadlamudi V. Acute Limb Ischemia Therapies: When and How to Treat Endovascularly. Semin Intervent Radiol 2019; 35:453-460. [PMID: 30728661 DOI: 10.1055/s-0038-1676321] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Acute limb ischemia is an emergent limb and life-threatening condition with high morbidity and mortality. An understanding of the presentation, clinical evaluation, and initial workup, including noninvasive imaging evaluation, is critical to determine an appropriate management strategy. Modern series have shown endovascular revascularization for acute limb ischemia to be safe and effective with success rates approaching surgical series and with similar, or even decreased, perioperative morbidity and mortality. A thorough understanding of endovascular techniques, associated pharmacology, and perioperative care is paramount to the endovascular management of patients presenting with acute limb ischemia. This article discusses the diagnosis and strategies for endovascular treatment of acute limb ischemia.
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Affiliation(s)
- Anthony N Hage
- Department of Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joseph L McDevitt
- Department of Radiology, University of Texas-Southwestern Medical Center, Dallas, Texas
| | | | - Venu Vadlamudi
- Department of Cardiovascular and Interventional Radiology, Inova Alexandria Hospital, Alexandria, Virginia
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ACR Appropriateness Criteria ® Iliac Artery Occlusive Disease. J Am Coll Radiol 2018; 14:S530-S539. [PMID: 29101990 DOI: 10.1016/j.jacr.2017.08.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 11/20/2022]
Abstract
Iliac artery occlusive disease can present as a sudden-onset acute thrombotic or thromboembolic event or as a chronic progressive atherosclerotic process that presents as claudication progressing to rest pain. Depending on the clinical presentation, the diagnosis is usually confirmed through Doppler vascular ultrasound, CT angiography, or MR angiography; the choice of imaging is usually based on modality availability and the presence of patient comorbidities such as chronic kidney disease. The Trans-Atlantic Inter-Society Consensus II classification system is commonly used to describe the extent of the peripheral vascular disease. Depending on the pathophysiology, clinical presentation, and radiologic extent of the disease process, therapeutic options for acute thrombotic cases can include supportive care, anticoagulation, thrombolytic therapy, surgical or catheter-directed mechanical thrombectomy, and surgical bypass. Therapeutic options for atherosclerotic disease include supportive measures such as behavior modification, a supervised exercise program, adjunctive treatment with anticoagulation and antiplatelet medications, angioplasty, stent placement, stent-graft placement, surgical or catheter-directed endarterectomy or plaque excision, and surgical bypass. This document describes the appropriateness of imaging in this patient population, treatment procedures for specific clinical scenarios, and the likely prognosis for these patients. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Li Z, Feng R, Qin F, Zhao Z, Yuan L, Li Y, Liu J, Feng J, Zhou J, Bao J, Jing Z. Recanalization of native superficial femoral artery chronic total occlusion after failed femoropopliteal bypass in patients with critical limb ischemia. J Interv Cardiol 2017; 31:207-215. [PMID: 29214670 DOI: 10.1111/joic.12470] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 10/29/2017] [Accepted: 11/06/2017] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES This study aimed to examine the outcomes of endovascular recanalization for native superficial femoral artery (SFA) chronic total occlusion (CTO) in patients with critical limb ischemia (CLI) after femoropopliteal bypass failure with limited surgical revascularization options. BACKGROUND Endovascular recanalization of native artery occlusions has been recently used as a new alternative for threatened limbs after bypass graft occlusion. The feasibility and efficacy has not been widely reported. METHODS We retrospectively analyzed 45 consecutive patients (45 limbs) undergoing endovascular recanalization of native SFA occlusion following failed femoropopliteal bypass between June 2010 and December 2016. RESULTS All limbs had Transatlantic Inter-Society Consensus class C (26.7%, 12/45) or D (73.3%, 33/45) lesions with a mean lesion length of 29.8 cm. The technical success rate was 95.6% (43/45 limbs). The ABI showed a significant increase from 0.3 ± 0.1 pre-procedure to 0.7 ± 0.1 post-procedure (P < 0.01). Two early (<30 days) below-knee amputations due to acute thrombotic ischemia occurred during perioperative period and resulted in one death due to myocardial infarction. The mean follow-up was 42.7 months (1-62 months). Two patients were lost to follow up. The primary patency rates at 12 and 36 months were 54% and 51%, respectively. Secondary patency rates at 12 and 36 months were 78% and 61%, respectively. Limb salvage rate was 95% and amputation-free survival rate was 88% at both 12 and 36 months. CONCLUSION Recanalization of native SFA CTO due to failed femoropopliteal bypass offers a feasible and safe alternative to surgical reconstruction with acceptable limb salvage.
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Affiliation(s)
- Zhenjiang Li
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Rui Feng
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Feng Qin
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China.,Department of Plastic Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Zhiqing Zhao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Liangxi Yuan
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yiming Li
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Junjun Liu
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jiaxuan Feng
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Jian Zhou
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Junmin Bao
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zaiping Jing
- Department of Vascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai, China
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Urbak L, de la Motte L, Rørdam P, Siddiqi A, Sillesen H. Catheter-Directed Thrombolysis in the Treatment of Acute Ischemia in Lower Extremities Is Safe and Effective, Especially with Concomitant Endovascular Treatment. Ann Vasc Dis 2017; 10:125-131. [PMID: 29034038 PMCID: PMC5579780 DOI: 10.3400/avd.oa.16-00140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate the influence of pre-procedural characteristics on immediate and late results as well as the safety of catheter-directed thrombolysis (CDT) in acute ischemia of the lower extremity. Materials and Methods: A retrospective study comprising 249 patients treated by CDT from January 2006 to December 2012. Outcomes were primary patency, haemorrhagic complications, amputation and mortality. Results: Primary patency for CDT alone was 68%, for CDT plus endovascular treatment 87% and for successful CDT with supplementary surgery 62% giving an overall primary patency of 76%. Two (0.8%) patients suffered from cerebral haemorrhage during CDT. We found a significant correlation between 30 day amputation rate and no visual distal run-off at CDT start (OR 2.31; CI95% 1.09–4.91; p-value=0.02) and onset of symptoms to CDT start of 8–14 days (OR 4.09; CI95% 1.42–11.81; p-value=0.01). Lack of visualized distal run-off was also associated with a significant risk of 30 day mortality (OR 5.84; CI95% 1.26–27.00; p-value=0.02). Conclusion: Our results show that CDT is a feasible and safe treatment option especially when combined with angioplasty +/− stent. However, no distal run-off at primary angiography is associated with higher rates of amputation during follow-up and 30 day mortality.
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Affiliation(s)
- Lærke Urbak
- Department of Vascular Surgery, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Louise de la Motte
- Department of Vascular Surgery, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Peter Rørdam
- Department of Vascular Surgery, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Aamir Siddiqi
- Department of Vascular Interventional Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
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Byrne RM, Taha AG, Avgerinos E, Marone LK, Makaroun MS, Chaer RA. Contemporary outcomes of endovascular interventions for acute limb ischemia. J Vasc Surg 2014; 59:988-95. [DOI: 10.1016/j.jvs.2013.10.054] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Revised: 10/03/2013] [Accepted: 10/06/2013] [Indexed: 10/25/2022]
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Patel NH, Krishnamurthy VN, Kim S, Saad WE, Ganguli S, Gregory Walker T, Nikolic B. Quality Improvement Guidelines for Percutaneous Management of Acute Lower-extremity Ischemia. J Vasc Interv Radiol 2013; 24:3-15. [DOI: 10.1016/j.jvir.2012.09.026] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 09/15/2012] [Accepted: 09/17/2012] [Indexed: 11/26/2022] Open
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Ochoa C, Weaver FA. Basic data related to thrombolytic therapy for acute arterial thrombosis. Ann Vasc Surg 2011; 26:292-7. [PMID: 22188940 DOI: 10.1016/j.avsg.2011.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 08/15/2011] [Indexed: 11/29/2022]
Affiliation(s)
- Christian Ochoa
- Division of Vascular Surgery and Endovascular Therapy, USC Cardiovascular Thoracic Institute, Keck School of Medicine, University of Southern California, Los Angeles, CA 90012, USA
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13
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Koraen L, Kuoppala M, Acosta S, Wahlgren CM. Thrombolysis for lower extremity bypass graft occlusion. J Vasc Surg 2011; 54:1339-44. [DOI: 10.1016/j.jvs.2011.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Revised: 05/09/2011] [Accepted: 05/09/2011] [Indexed: 10/18/2022]
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Schwarz H, Abassi Z, Nitecki S, Karram T, Engel A, Ofer A, Hoffman A. Thrombolytic therapy in ischemic limbs: Is it a worthwhile therapeutic option? Int J Angiol 2011. [DOI: 10.1007/s00547-005-1071-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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15
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Gargiulo NJ, O'Connor DJ. Proportion of Patients with Critical Limb Ischemia who Require an Open Surgical Procedure in a Center Favoring Endovascular Treatment. Am Surg 2011. [DOI: 10.1177/000313481107700321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular interventions have gained widespread acceptance as primary and secondary treatments for critical lower extremity ischemia (CLI), and many believe there is little need for open bypasses for CLI. Despite this, some patients presenting with CLI require traditional lower extremity bypass procedures at some point for successful limb salvage. To determine the proportion of patients requiring an open procedure, we reviewed our 1-year experience with CLI patients at a center committed to endovascular approaches whenever possible. We reviewed all patients presenting with CLI from January 1, 2007 to December 31, 2007. CLI was defined as ischemic rest pain, nonhealing ulceration, or gangrene for which a major amputation was imminently required. All patients underwent duplex and conventional angiography before intervention. Endovascular treatments were favored as primary, secondary, or tertiary treatments, if possible. If these failed or were impossible, standard lower extremity bypasses were performed. One hundred and forty-eight patients presented with primary, secondary, or tertiary CLI over this 1-year period. Of these, 63 (42%) were treated successfully with an endovascular intervention, and 69 (47%) required standard lower extremity bypass, and 16 (11%) required a combined endovascular and open procedure (i.e., hybrid procedure). Of these 148 patients, 46 (31%) were presenting with secondary, tertiary, or more CLI after failed previous (1-5) procedures. Despite the initial enthusiasm that the majority of patients presenting with CLI may be treated with endovascular procedures, there exists a significant cohort of patients that will ultimately require standard open surgical procedures.
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Affiliation(s)
- Nicholas J. Gargiulo
- Department of Surgery, Division of Vascular Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
| | - David J. O'Connor
- Department of Surgery, Division of Vascular Surgery, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York
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Abraham-Igwe C, Siddiqui M, Geddes L, Halls J, Irvine A, Browning N. A retrospective study examining thrombolysis for occluded femoro-popliteal grafts – Is it worthwhile? Int J Surg 2011; 9:632-5. [DOI: 10.1016/j.ijsu.2011.07.431] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 07/09/2011] [Accepted: 07/26/2011] [Indexed: 11/25/2022]
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Allaqaband S, Kirvaitis R, Jan F, Bajwa T. Endovascular treatment of peripheral vascular disease. Curr Probl Cardiol 2009; 34:359-476. [PMID: 19664498 DOI: 10.1016/j.cpcardiol.2009.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Peripheral arterial disease (PAD) affects about 27 million people in North America and Europe, accounting for up to 413,000 hospitalizations per year with 88,000 hospitalizations involving the lower extremities and 28,000 involving embolectomy or thrombectomy of lower limb arteries. Many patients are asymptomatic and, among symptomatic patients, atypical symptoms are more common than classic claudication. Peripheral arterial disease also correlates strongly with risk of major cardiovascular events, and patients with PAD have a high prevalence of coexistent coronary and cerebrovascular disease. Because the prevalence of PAD increases progressively with age, PAD is a growing clinical problem due to the increasingly aged population in the United States and other developed countries. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, endovascular practice, percutaneous transluminal angioplasty with or without stenting, is used far more frequently for all types of lower extremity occlusive lesions, reflecting the continuing advances in imaging techniques, angioplasty equipment, and endovascular expertise. The role of endovascular intervention in the treatment of limb-threatening ischemia is also expanding, and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes percutaneous transluminal angioplasty/stenting an attractive alternative to surgery and, as most endovascular interventions are performed on an outpatient basis, hospital costs are cut considerably. In this monograph we discuss current endovascular intervention for treatment of occlusive PAD, aneurysmal arterial disease, and venous occlusive disease.
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18
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Quality Improvement Guidelines for Percutaneous Management of Acute Limb Ischemia. J Vasc Interv Radiol 2009; 20:S208-18. [DOI: 10.1016/j.jvir.2009.04.010] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Plate G, Oredsson S, Lanke J. When is Thrombolysis for Acute Lower Limb Ischemia Worthwhile? Eur J Vasc Endovasc Surg 2009; 37:206-12. [DOI: 10.1016/j.ejvs.2008.11.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2008] [Accepted: 11/07/2008] [Indexed: 11/25/2022]
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Cubillas-Martín H, Hernández-La Hoz Ortiz I, García-Casas J, Franco-Meijide F, Caicedo-Valdés D, Cenizo-Revuelta N. Recanalización tardía de injerto ilíaco. ANGIOLOGIA 2008. [DOI: 10.1016/s0003-3170(08)05006-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Plate G, Jansson I, Forssell C, Weber P, Oredsson S. Thrombolysis for Acute Lower Limb Ischaemia—A Prospective, Randomised, Multicentre Study Comparing Two Strategies. Eur J Vasc Endovasc Surg 2006; 31:651-60. [PMID: 16427339 DOI: 10.1016/j.ejvs.2005.11.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2005] [Accepted: 11/17/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To test if initial high-dose, pulse-spray thrombolysis improves the early and late outcome of lower limb ischaemia as compared with low-dose infusion alone. DESIGN Prospective randomised multicentre study. MATERIAL AND METHODS Patients with acute and sub-acute (<30 days) lower limb ischaemia were randomised following angiography. Group 1 (n=58) received pulse-spray infusion of recombinant plasminogen activator (rt-PA, 15 mg/h) for 2h followed by low-dose infusion if needed. Group 2 (n=63) were only treated with low-dose infusion (0.5mg/h) of rt-PA for 48 h. Underlying lesions were corrected if required. RESULTS The study was stopped prematurely. Complications were equally frequent in both groups. More than 75% lysis was accomplished in 78 versus 67% of the patients (p=0.21). Primary endpoints (re-occlusion, incomplete lysis, life-threatening complication, amputation, or death) were reached in 24 versus 32% of the patients (p=0.35). Neither vascular patency nor clinical parameters differed during the first year, but re-interventions tended to be more frequent (p=0.040 at 1 month; p=0.090 at 1 year) and of a greater magnitude (p=0.028) in group 2. CONCLUSIONS There was no obvious advantage with initial high-dose thrombolysis, which may be a type-2 error. A reduction of major re-interventions was recorded.
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Affiliation(s)
- G Plate
- Department of Surgery, Central Hospital, Helsingborg, Sweden.
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Tepe G, Hopfenzitz C, Dietz K, Wiskirchen J, Heller S, Ouriel K, Ziemer G, Claussen CD, Duda SH. Peripheral Arteries: Treatment with Antibodies of Platelet Receptors and Reteplase for Thrombolysis—APART Trial. Radiology 2006; 239:892-900. [PMID: 16641342 DOI: 10.1148/radiol.2393050620] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively compare the safety and efficacy of combination therapy with the glycoprotein IIb/IIIa antagonist abciximab plus the third-generation thrombolytic agent reteplase versus those of therapy with the standard thrombolytic agent urokinase plus abciximab. MATERIALS AND METHODS The study was approved by the local ethics committee, and patient informed consent was obtained. Patients with peripheral arterial occlusions less than 60 days old (n=120) were enrolled in the study: 50 patients (32 men, 18 women; mean age, 67 years; range, 23-88 years) received reteplase plus abciximab and 70 patients (36 men, 34 women; mean age, 68 years; range, 28-88 years) received urokinase plus abciximab. Study end points were the rate of major complications at 30 days, therapeutic success, and survival without open surgery or major amputation at follow-up. Fisher exact test was used to compare treatment groups with respect to dichotomous variables, and the event-free-survival probabilities were calculated with the Kaplan-Meier method. For the comparison of the lengths of occlusions among the groups, a two-sample t test was used. RESULTS Therapeutic success (P=.7) did not differ between the groups, whereas the time required for thrombolysis was lower in the urokinase-plus-abciximab group (P=.001). Patients who received reteplase plus abciximab tended to develop more minor complications (mainly bleeding events) (P<.001). During long-term follow-up (2-4 years), no group differences were observed. The reocclusion rate was 48% (22 of 46) in the reteplase-plus-abciximab group and 45% (29 of 64) in the urokinase-plus-abciximab group. Only two of 120 major amputations were counted in the follow-up period. CONCLUSION The proposed regimen resulted in only a limited number of major complications, and the low amputation rate in both groups may be attributed to abciximab.
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Affiliation(s)
- Gunnar Tepe
- Department of Diagnostic Radiology, University of Tübingen, Tübingen, Germany.
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Killewich LA. Improving Functional Status and Quality of Life in Elderly Patients with Peripheral Arterial Disease. J Am Coll Surg 2006; 202:345-55. [PMID: 16427563 DOI: 10.1016/j.jamcollsurg.2005.09.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2005] [Revised: 09/26/2005] [Accepted: 09/28/2005] [Indexed: 10/25/2022]
Affiliation(s)
- Lois A Killewich
- Section of Vascular Surgery, Department of Surgery, The University of Texas Medical Branch, Galveston, TX 77555, USA
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24
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Acute Arterial Occlusion. Vasc Med 2006. [DOI: 10.1016/b978-0-7216-0284-4.50052-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Unsuspected subclavian or axillary disease may cause failure of axillofemoral bypass grafts. A 52-year-old woman who underwent left axillofemoral bypass grafting 5 years ago presented with 24 h of left foot pain. Routine duplex ultrasonography 2 months previously demonstrated velocities throughout the graft > 80 cm/s. Emergent angiography revealed thrombotic occlusion of the axillofemoral bypass graft. Both rheolytic thrombectomy and pulse spray thrombolysis using tissue plasminogen activator were used to restore graft patency. Arterial pressure waveform and pressure remained damped throughout the graft; a 50 mmHg gradient was found from the descending thoracic aorta to the mid-left subclavian artery. Angiography revealed a 70% diameter stenosis at the origin of the left subclavian artery. Following balloon angioplasty and stent placement, the pressure gradient was eliminated. In conclusion, careful evaluation of arterial inflow to bypass grafts is critical for ensuring long-term graft patency.
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Affiliation(s)
- David P Slovut
- Department of Cardiology, St Mary's/Duluth Clinic Heart Center, Duluth, Minnesota, USA.
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Rajan DK, Patel NH, Valji K, Cardella JF, Bakal C, Brown D, Brountzos E, Clark TWI, Grassi C, Meranze S, Miller D, Neithamer C, Rholl K, Roberts A, Schwartzberg M, Swan T, Thorpe P, Towbin R, Sacks D. Quality Improvement Guidelines for Percutaneous Management of Acute Limb Ischemia. J Vasc Interv Radiol 2005; 16:585-95. [PMID: 15872313 DOI: 10.1097/01.rvi.0000156191.83408.b4] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Dheeraj K Rajan
- Department of Radiology, University of Health Network, Toronto, Ontario, Canada
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Earnshaw JJ, Whitman B, Foy C. National Audit of Thrombolysis for Acute Leg Ischemia (NATALI): clinical factors associated with early outcome. J Vasc Surg 2004; 39:1018-25. [PMID: 15111854 DOI: 10.1016/j.jvs.2004.01.019] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The National Audit of Thrombolysis for Acute Leg Ischemia (NATALI) database is a consecutive series of patients who underwent intra-arterial thrombolysis to treat acute leg ischemia in one of 11 centers in the United Kingdom. The purpose of the study was to analyze the factors associated with outcome after 30 days. METHODS The data were collected over 10 years on standard pro formas, and registration was completed at the end of 1999. Since then, data from each unit have been verified and missing data included when available. Univariate and multivariate analyses were performed, with the outcomes of amputation-free survival (AFS), amputation with survival, and death. RESULTS A total of 1133 thrombolytic events were included. Outcome results at 30 days for the entire group were AFS, 852 (75.2%); amputation, 141 (12.4%); and death, 140 (12.4%). Results for the entire group improved from the first half of the database, when AFS ranged from 65% to 75%, to almost 80% for the last few years of the study, although this was not statistically significant. Preintervention factors associated with lower AFS at multivariate analysis included diabetes (P =.002), increasing age (P <.001), short-duration ischemia (P =.027), Fontaine grade (P =.001), and ischemia with neurosensory deficit (P =.004). AFS was improved in patients receiving warfarin sodium at the time of the arterial occlusion (P =.04). Mortality was higher in women (P =.006) and in older patients (P <.001), and in patients with native vessel occlusion (P <.001), emboli (P =.02), or a history of ischemic heart disease (P <.001). Amputation risk was greatest in younger men (P <.001) and in patients with more severe ischemia (P =.02), graft occlusion (P <.001), or native vessel thrombotic occlusion (P =.02). CONCLUSION Experienced surgeons and radiologists can achieve an AFS of about 80% in selected patients with acute leg ischemia. Information from the NATALI database can be used in selection of an appropriate intervention in the individual patient.
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Costanza MJ, Neschis DG, Queral LA, Flinn WR. Surgical Thrombectomy and Transluminal Balloon Angioplasty for Failed Above-knee Femoropopliteal Polytetrafluoroethylene Bypass Grafts. Ann Vasc Surg 2004; 18:186-92. [PMID: 15253254 DOI: 10.1007/s10016-004-0011-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Endovascular therapy offers an alternative to redo bypass or surgical graft revision for failed above-knee femoropopliteal PTFE bypass grafts. We evaluated the outcome of surgical thrombectomy and balloon angioplasty for the treatment of thrombosed bypass grafts. Thirty selected patients with thrombosed above-knee femoropopliteal PTFE bypass grafts were treated. Under local anesthesia, a surgical thrombectomy followed by bypass graft angiography and balloon angioplasty of perianastomotic stenoses was performed. Stents were used selectively for suboptimal angioplasty results. Patients underwent duplex scanning of the bypass graft postoperatively and at 6-month intervals. Life-table analysis and log-rank (Mantel-Cox) comparisons were performed. Patients were categorized into two groups on the basis of time elapsed from initial bypass graft construction to graft failure. Group 1 included 21 patients with a mean time to graft failure of 10 months (range, 0-20). Surgical thrombectomy was successful in 20 grafts (95%) and 17 patients had a stent placed after angioplasty. Rethrombosis occurred within 30 days in seven grafts (33%) in group 1 and major amputations were performed in six patients (28%). Group 2 included nine patients with a mean time to initial bypass graft failure of 48 months (range, 29-96). All patients in group 2 had a successful surgical thrombectomy and all received a stent. None of the grafts treated in group 2 reoccluded within 30 days of intervention and one patient (11%) went on to require a major amputation. By life-table analysis, the 6- and 12-month patency for group 1 was 15.3% and 5.1%, compared to 58.3% and 38.9% for group 2 (p = 0.027). Surgical thrombectomy along with balloon angioplasty has an unacceptably high rate of failure and limb loss in patients treated for early (<2 years) femoropopliteal PTFE bypass graft thrombosis. Surgical graft revision or redo bypass is recommended to achieve successful revascularization in these patients. Treatment with surgical thrombectomy and balloon angioplasty achieves significantly greater short-term patency results in patients with late (>2 years) bypass graft failure and may be a reasonable alternative for patients who cannot tolerate reoperation or lack autogenous conduit.
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Nehler MR, Hiatt WR, Taylor LM. Is revascularization and limb salvage always the best treatment for critical limb ischemia? J Vasc Surg 2003; 37:704-8. [PMID: 12618724 DOI: 10.1067/mva.2003.142] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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