Pedal bypass in the treatment of critical ischemia in the diabetic foot

A formerly established theory on obliteration of diabetic foot arteries was dismissed. In the last decade, diabetic foot revascularization using so called very distal bypass has became a routine procedure. The reconstructions are undertaken in patients with chronic critical limb ischemia. This paper presents our initial experience with this, not yet widely used, operative technique in 16 patients who had a total of 14 pedal bypass procedures performed. The parameters we monitored included the 3-, 6-, and 12-month patency rates, defect healing, and limb salvage rates. The primary and secondary patency rates were 64.3% and 78.6% at 3 months; 55.5% and 66.7% at 6 months; and 50% and 75% at one year, respectively. The overall limb salvage rate for the above periods was 92.9%. All defects healed following successful revascularization using pedal bypass. In patients where bypass could not be established, limb salvage was accomplished in one in three cases only.     

A new minimally invasive hybrid technique for femoro - above knee popliteal bypass

Femoro above knee popliteal bypass using synthetic graft is a well recognized revascularization procedure in patients with severe lower limb ischemia with either critical limb ischemia (CLI), limiting claudication (IC) or with acute limb ischemia (ALI).Occasionally the patient's general condition would mandate a short and minimally invasive procedure. When endovascular revascularization is not possible or fails then the peripheral VORTEC technique is used. A telescopic sutureless anastomosis is created between an ePTFE graft to the above knee popliteal artery with a bridging piece of VIABHAN. The technique was described in detail and has been published in the August 2011 issue of the EJVES. Between April 2010 and October 2011 seventeen procedures were accomplished successfully in 16 patients. The median follow up was 13 months (range 3-17). Two patients died during follow up from unrelated caused, both from acute cardiac events and both with patent bypasses, one and 5 months after the index operation. There were 2 occasions of limb loss but only one graft loss related amputation. There were 4 thrombectomies for graft occlusions. All four did not have a distal anastomotic stenosis that could predict graft failure on pre occlusion follow up duplex scans. Primary patency for the whole cohort was 65%, the primary assisted patency was 70% and the secondary patency was 85%. In conclusion we believe that this technique could be advantageous in morbid patients and we therefore recommend using it in high risk patients if no endovascular option or saphenous vein are available.     

Critical limb ischemia: does long-term patency matter?

In critical limb ischemia (CLI), an underlying principle of treatment is that it takes more oxygenated blood to heal a wound than to maintain tissue integrity. Urgent restoration of perfusion to the ischemic territory, not long-term patency of the target vessel, is the primary treatment goal. However, in patients with CLI treated by surgical bypass, loss of graft patency is associated with poor outcomes. We decided to address the conventional wisdom that restenosis is not a major concern in CLI as long as tissue healing occurs in patients undergoing endovascular revascularization. We retrospectively reviewed the records of consecutive patients treated for CLI with infra-popliteal percutaneous revascularization from 2007 to 2009. Those with prior ipsilateral percutaneous revascularization for CLI formed the study population. Among 29 CLI patients treated for infra-popliteal revascularization, six patients had a history of prior successful ipsilateral revascularization for CLI. All six patients were free of rest pain and ulcers at the 60-day follow-up. The median time interval between the two percutaneous revascularization procedures was 21 months (quartile ranges: 25th = 4.5 months, 75th = 36 months). Five of the six patients had restenosis of a previous lesion, while the sixth patient had a de novo lesion causing recurrent CLI. In conclusion, we found that one in five patients receiving infra-popliteal angioplasty for CLI has had a similar percutaneous revascularization procedure in the past. Among these patients most cases were for restenosis rather than de novo lesions. Further research is needed to determine whether the incidence of recurrent CLI is due to de novo lesions or restenosis. Close clinical follow-up of these patients and maintaining long-term patency with endovascular techniques will likely reduce CLI recurrence.     

Femoral artery percutaneous revascularization for patients with critical limb ischemia: outcomes compared to patients with claudication over 2.5 years

Patients with critical limb ischemia have higher rates of death and amputation after revascularization compared to patients with intermittent claudication. However, the differences in patency after percutaneous revascularization of the superficial femoral artery are uncertain and impact the long-term risk of amputation and function in critical limb ischemia. We identified 171 limbs from 136 consecutive patients who had angioplasty and/or stenting for super?cial femoral artery stenoses or occlusions from July 2003 through June 2007. Patients were followed for primary and secondary patency, death and amputation up to 2.5 years, and 111 claudicants were retrospectively compared to the 25 patients with critical limb ischemia. Successful percutaneous revascularization occurred in 128 of 142 limbs (90%) with claudication versus 25 of 29 limbs (86%) with critical limb ischemia (p = 0.51). Overall secondary patency at 2.5 years was 91% for claudication and 88% for critical limb ischemia. In Cox proportional hazards models, percutaneous revascularization for critical limb ischemia had similar long-term primary patency (adjusted hazard ratio = 1.1, 95% CI = 0.4, 2.6; p = 0.89) and secondary patency (adjusted hazard ratio = 1.1, 95% CI = 0.2, 6.0; p = 0.95) to revascularization for claudication. Patients with critical limb ischemia had higher mortality and death rates compared to claudicants, with prior statin use associated with less death (p = 0.034) and amputation (p = 0.010), and prior clopidogrel use associated with less amputation (p = 0.034). In conclusion, percutaneous superficial femoral artery revascularization is associated with similar long-term durability in both groups. Intensive treatment of atherosclerosis risk factors and surveillance for restenosis likely contribute to improving the long-term outcomes of both manifestations of peripheral artery disease.     

Endovascular reconstruction of popliteal and infrapopliteal arteries for limb salvage and wound healing in patients with critical limb ischemia – A retrospective analysis

BackgroundAdvancement in endovascular techniques has led to rapid growth in endovascular revascularization, and it has emerged as a treatment for critical limb ischemia (CLI). Clinical effectiveness of revascularization has been frequently judged by vessel patency and limb salvage, but there is paucity of reports on outcomes of the wound. We present a retrospective analysis of immediate angiographic and 3-month clinical outcome of patients who underwent endovascular reconstruction of popliteal and infrapopliteal arteries for CLI.MethodsAll patients who underwent endovascular reconstruction of popliteal and/or infrapopliteal arteries for CLI and >70% stenosis on digital subtraction angiography between March 2010 and November 2014 and had a clinical follow-up of at least 3 months were selected for analysis.Results34 patients underwent endovascular reconstruction. 9 patients (26%) underwent only POBA and remaining 25 (74%) underwent additional stenting. 13 patients (38%) had multiple segmental revascularization. 24 patients (71%) had successful vessel recanalization. Linear flow to foot in at least one artery could be achieved in 20 patients (59%) post revascularization. Successful wound healing occurred in 11 (35%) patients with an additional 7 (21%) patients showing clinical improvement in their wounds. Limb salvage was achieved in 33 patients (97%) at 3-month follow-up.ConclusionEndovascular revascularization of popliteal and infrapopliteal arteries is a feasible, safe, and effective procedure for the treatment of CLI. Normal inflow and outflow with at least one of the three infrapopliteal vessels being patent is essential for adequate healing of chronic ulcers and prevention of major amputation.     

Infrainguinal revascularization based on duplex ultrasound arterial mapping.

AIM: Recent reports have advocated duplex ultrasound arterial mapping (DUAM) as the sole preoperative imaging modality for planning infrainguinal revascularization. This study reports the outcome of arterial revascularization procedures for chronic limb ischemia based on DUAM. METHODS: From January 2002 to December 2004, 253 patients (175 men, 78 women) underwent infrainguinal revascularization based on DUAM. The indications for surgery were severe claudication (11%), rest pain (15%), gangrene (40%), non-healing ulcer (34%). Preoperative evaluation consisted of DUAM alone in 208 cases (82%) or a combination of DUAM and contrast arteriography (CA) in 30 (12%) and intraoperative angiography or direct exploration in 15 (6%). DUAM allowed imaging from the distal aorta to the pedal arteries and the selection of inflow and outflow bypass anastomosis sites. CA was deemed necessary due to technical difficulties or medico-legal reasons. RESULTS: DUAM procedure time averaged 90+30 min. Proximal anastomosis was located in common femoral arteries in 202 cases, popliteal in 51. Distal anastomosis was to the tibial arteries in 144 cases and pedal arteries in 109. Primary patency was 89% and 67% at 12 and 36 months. Secondary patency was 93% and 82% at 12 and 36 months. CONCLUSIONS: This experience shows that DUAM may be a safe alternative to CA for patients with chronic limb ischemia. Adequate training and experience is necessary to utilize this technique as the sole preoperative imaging modality for planning infrainguinal revascularization.     

Wireless laser-assisted angioplasty of the superficial femoral artery in patients with critical limb ischemia who have failed conventional percutaneous revascularization.

Percutaneous revascularization has become an effective treatment for patients suffering from chronic critical limb ischemia (CLI) due to chronic atherosclerotic obstructions, including total occlusions. Unlike other vascular beds, total chronic occlusions of the femoropopliteal arteries are frequently found in patients with severe claudication or CLI. As a consequence, patients with long chronic total occlusions of the femoropopliteal arteries are generally not considered optimal candidates for percutaneous revascularization and are frequently referred for surgical revascularization. In the present study, we sought to evaluate the feasibility, safety, and outcome of a modified wireless laser ablation technique to recanalize total occlusions in patients with CLI who had failed conventional percutaneous techniques for limb salvage. Procedural success, complications, actuarial freedom of limb loss, and surgical revascularization were evaluated in 25 patients after a mean follow-up of 13 +/- 8 months. Procedural success was achieved in 21 patients (84%). Actuarial freedom from surgical revascularization or limb loss was 72%. There was one vascular perforation. No deaths or distal embolization occurred. Three patients (12%) required limb amputation during follow-up, whereas four patients (16%) had surgical revascularization in the presence of feasible vascular targets. Limb salvage was achieved in 88% of patients when laser recanalization was combined with surgical revascularization. These results suggest that the use of laser ablation is safe and facilitates angioplasty and stenting in patients with CLI that failed conventional endovascular revascularization. This technique might prevent limb loss in patients with CLI due to femoropopliteal total occlusions, particularly in patients with unsuitable anatomy for surgical revascularization.     

Infrainguinal endovascular procedures based upon the results of duplex scanning.

AIM: The aim of this study was to report the role of duplex scanning in selection of patients with lower limb ischemia for infrainguinal endovascular revascularization. METHODS: From January 2002 to December 2005, 95 patients (66 male, 29 female) underwent infrainguinal endovascular revascularization based on duplex scanning. The indications for surgery were severe claudication (11%), rest pain (15%), gangrene (40%), and non-healing ulcer (34%). RESULTS: Duplex procedure time averaged 60+/-30 min. A total of 120 arterial hemodynamic relevant lesions were treated with endovascular therapy, 47 were localized in the aorto-iliac segment, 55 in the femoro-popliteal segment and 18 were infrapopliteal. Out of a total of 120 lesions, 107 (89%) were successfully dilated; 105 lesions (88%) predicted by preoperative duplex scanning were confirmed by contrast arteriography (CA) at the time of surgery. Additional lesions were revealed by intraoperative arteriography in 15 cases (12%). The accuracy and sensitivity of duplex scanning in the selection of aorto-iliac lesions for endovascular procedures was 86%, 91% for femoro-popliteal lesions, and 78% for infrapopliteal lesions. CONCLUSION: The results of this experience show that duplex scanning may be a safe alternative to CA for patients with chronic limb ischemia. Adequate training and experience is necessary to utilize this technique for the selection of patients for infrainguinal endovascular procedures.     

Primary extraanatomical revascularization for groin infections in drug addicts

BACKGROUND: Arterial groin infections in drug addicts are associated with a risk of amputation and are potentially lethal. Primary revascularization with an obturator bypass represents a potential alternative to local revision and arterial ligation alone. We report our experience with this approach. PATIENTS AND METHODS: From January 1999 until December 2005 twelve drug addicts were treated due to arterial infections in the groin. In eight patients (seven men, one woman, 31 years old on average), the defect in the artery could not be repaired and ligation of the femoral vessels led to critical ischemia. Therefore, an iliaco-popliteal bypass via the foramen obturatorium was implanted either primarily or secondarily. In three patients a cryopreserved homologous vein was used, five patients received alloplastic grafts. RESULTS: Four of eight obturator bypasses were implanted primarily. In the other four patients the initial treatment was limited to local debridement and artery ligation and an obturator bypass was implanted at a later date. Two grafts occluded within the first 30 days. Thereof one was successful thrombectomized. The other patient had no critical ischemia and he refused further surgery. Three more grafts occluded at 74, 90 and 103 days after surgery. No patient demonstrated signs of graft infection and all groin incisions healed uneventfully. A lower limb amputation became necessary in one patient even though the reconstruction was patent due to embolisation of mycotic material. All patients remained drug dependent throughout the followup time which was 3 months on average and ranged from one to 40 months. CONCLUSIONS: The patency of obturator bypasses was 75% at one month. This appears low, especially if one considers the youthful age of the patients and the absence of arterial occlusive disease. Nevertheless, the amputation rate also remained low. Therefore, we feel that this technique may contribute to limb salvage in groin infections in drug addicts.     

Iloprost in the management of peripheral arterial disease in patients with diabetes mellitus

Diabetic complications in the lower extremities, especially those secondary to diabetic macroangiopathy, have increasingly become a clinical emergency, given the high prevalence and progression of the disease. Until recently, the only approach to treating advanced stage disease was medical therapy and major amputation; however, the advent of revascularization procedures has radically improved the prognosis of patients with critical lower limb ischemia. In this setting, iloprost holds a dual position: as first-choice therapy in patients ineligible for revascularization and as complementary therapy in candidates for surgical or endovascular revascularization.     

Prognostic Value of Radiotracer-Based Perfusion Imaging in Critical Limb Ischemia Patients Undergoing Lower Extremity Revascularization

ObjectivesThe purpose of this study was to evaluate the prognostic value of single-photon emission computed tomography (SPECT)/computed tomography (CT) imaging of angiosome foot perfusion for predicting amputation outcomes in patients with critical limb ischemia (CLI) and diabetes mellitus (DM).BackgroundRadiotracer imaging can assess microvascular foot perfusion and identify regional perfusion abnormalities in patients with critical limb ischemia CLI and DM, but the relationship between perfusion response to revascularization and subsequent clinical outcomes has not been evaluated.MethodsPatients with CLI, DM, and nonhealing foot ulcers (n = 25) were prospectively enrolled for SPECT/CT perfusion imaging of the feet before and after revascularization. CT images were used to segment angiosomes (i.e., 3-dimensional vascular territories) of the foot. Relative changes in radiotracer uptake after revascularization were evaluated within the ulcerated angiosome. Incidence of amputation was assessed at 3 and 12 months after revascularization.ResultsSPECT/CT detected a significantly lower microvascular perfusion response for patients who underwent amputation compared with those who remained amputation free at 3 (p = 0.01) and 12 (p = 0.01) months after revascularization. The cutoff percent change in perfusion for predicting amputation at 3 months was 7.55%, and 11.56% at 12 months. The area under the curve based on the amputation outcome was 0.799 at 3 months and 0.833 at 12 months. The probability of amputation-free survival was significantly higher at 3 (p = 0.002) and 12 months (p = 0.03) for high-perfusion responders than low-perfusion responders to revascularization.ConclusionsSPECT/CT imaging detects regional perfusion responses to lower extremity revascularization and provides prognostic value in patients with CLI (Radiotracer-Based Perfusion Imaging of Patients With Peripheral Arterial Disease; NCT03622359)     

Endovascular therapy for chronic mesenteric ischemia.

OBJECTIVES: We sought to describe the outcomes of a consecutive series of patients with chronic mesenteric ischemia (CMI) who were treated with percutaneous stent revascularization. BACKGROUND: Historically, the treatment for CMI has been surgical revascularization. However, surgery carries a significant procedural complication rate and mortality. METHODS: Fifty-nine consecutive patients with CMI underwent stent placement in 79 stenotic (>70%) mesenteric arteries. All patients had clinical follow-up and 90% had anatomical follow-up with angiography (computed tomography or conventional) or ultrasound at > or =6 months after the procedure. RESULTS: Procedural success was obtained in 96% (76 of 79 arteries) and symptom relief occurred in 88% (50 patients). At a mean follow-up of 38 +/- 15 months (range, 6 to 112 months), 79% of the patients remained alive, and 17% (n = 10) experienced a recurrence of symptoms. Angiography or ultrasound obtained at 14+/- 5 months after the procedure demonstrated a restenosis rate of 29% (n = 20). All patients with recurrent symptoms had angiographic in-stent restenosis and were successfully revascularized percutaneously. CONCLUSIONS: Percutaneous stent placement for the treatment of CMI can be performed with a high procedural success and a low complication rate. The long-term freedom from symptoms and vascular patency are comparable with surgical results. The inherent lower procedural morbidity and mortality makes the endovascular approach the preferred revascularization technique for these patients.     

Pedal-plantar loop technique for a challenging below-the-knee chronic total occlusion: a novel approach to percutaneous revascularization in critical lower limb ischemia

Arterial revascularization by means of percutaneous transluminal angioplasty (PTA) is a mainstay in the management of patients with peripheral artery disease and critical limb ischemia (CLI). However, when employing standard approaches, percutaneous transluminal angioplasty (PTA) of below-the-knee arteries may fail in up to 20% of cases. In the present article, we report on a novel interventional strategy, the pedal-plantar loop technique, which we successfully employed in a patient with critical lower limb ischemia. This technique may sensibly increase success rates of PTA in very challenging total occlusions of below-the-knee arteries (e.g., those lacking a proximal occlusion stump). Technical points pertinent to this case are clearly illustrated, including the need to accurately choose guidewires and balloons of appropriate length, and the extensive use of the subintimal angioplasty technique.     

Critical limb ischemia: medical and surgical management

AbstractChronic critical limb ischemia (CLI), defined as > 2 weeks of rest pain, ulcers, or tissue loss attributed to arterial occlusive disease, is associated with great loss of both limb and life. Therapeutic goals in treating patients with CLI include reducing cardiovascular risk factors, relieving ischemic pain, healing ulcers, preventing major amputation, improving quality of life and increasing survival. These aims may be achieved through medical therapy, revascularization, or amputation. Medical therapy includes administration of analgesics, local wound care and pressure relief, treatment of infection, and aggressive therapy to modify atherosclerotic risk factors. For patients who are not candidates for revascularization, and who are unwilling or unable to undergo amputation, treatments such as intermittent pneumatic compression or spinal cord stimulation may offer symptom relief and promote wound healing. Revascularization offers the best option for limb salvage. The decision to perform surgery, endovascular therapy, or a combination of the two modalities ('hybrid' therapy) must be individualized. Patients who are relatively fit and able to withstand the rigors of an open procedure may benefit from the long-term durability of surgical repair. In contrast, frail patients with a limited life expectancy may experience better outcomes with endovascular reconstruction. Hybrid therapy is an attractive option for patients with limited autologous conduit, as it permits complete revascularization with a less extensive procedure, shorter duration of operation, and decreased risk of peri-operative complications. Amputation should be considered for patients who are non-ambulatory, demented, or unfit to undergo revascularization.     

Homocysteine, the cholesterol of the 21st century. Impact of hyperhomocysteinemia on patency and amputation-free survival after intervention for critical limb ischemia

PURPOSE: To assess the prevalence of hyperhomocysteinemia and determine any correlation to the clinical and technical outcome of peripheral arterial revascularization for critical limb ischemia (CLI). METHODS: Between October 1, 2002, and December 31, 2006, 953 revascularization procedures were performed for CLI in a high-volume tertiary referral vascular/endovascular unit. Fasting plasma homocysteine was accurately measured preoperatively in 225 patients (124 men; mean age 75.8 years, range 45-98), who formed the basis for the study. All patients had multilevel disease (TASC II C and D lesions), and 73% had single vessel runoff. Composite primary endpoints included primary, assisted primary, and secondary patency; amputation-free survival; and all-cause mortality. RESULTS: The prevalence of hyperhomocysteinemia was 30% [69 patients (36 men; mean age 78.2 years, range 53-93)]; most (88%) of the patients showed a mild elevation in homocysteine (13-20 micromol/L). Patients with hyperhomocysteinemia had significantly lower primary, assisted primary, and secondary patency rates at all intervals to 36 months (3.3%, 10.8%, and 11.2%, respectively; p<0.001) after the intervention compared to patients with normal homocysteine levels (50.8%, 54.6%, and 57.1%, respectively). The mean amputation-free survival was significantly lower for patients with hyperhomocysteinemia (54.8% versus 81.0%, p=0.008). Overall, 27% of the normal homocysteine group progressed to vessel occlusion compared to 65% of the hyperhomocysteinemia group (p<0.0001). There was no significant difference between groups with respect to 4-year cumulative all-cause mortality (p=0.331). In a multivariate logistic regression analysis, only a homocysteine level >13.0 micromol/L was found to be significantly associated with adverse outcomes, such as amputation (OR=3.4, 95% CI 1.27 to 9.01; p=0.015) and graft occlusion (OR=7.97, 95% CI 3.63 to 17.5; p<0.0001). CONCLUSION: Hyperhomocysteinemia appears to be an independent risk factor for the progression of vascular disease and is an adverse prognostic factor for CLI patients undergoing peripheral arterial revascularization.     

Stenting of the superficial femoral artery after suboptimal balloon angioplasty: one-year results.

AIM: The aim of this study was to analyze the intermediate results of selective stenting of superficial femoral artery (SFA) lesions after a suboptimal balloon angioplasty result. METHODS: We analyzed 70 consecutive patients with claudication or critical limb ischemia due to peripheral arterial occlusive disease who underwent stent implantation of the SFA after unsuccessful balloon-angioplasty. All patients were followed-up immediately after the procedure and 3, 6 and 12 months thereafter. Restenosis was defined as an increase of peak systolic velocity-index >2 as determined by duplex sonography. RESULTS: Primary patency rates at 3, 6 and 12 months were 83.4%, 66.2% and 59%, respectively. Successful reinterventions were performed for 17 reobstructions, resulting in a secondary patency rate at 3, 6 and 12 months of 91%, 89.3%, and 83.8%, respectively. At 12 months 68.6% of the patients were asymptomatic, 21.6% complained of mild (Fontaine class II a), 5.9% of severe (Fontaine class II b) claudication and 2.9% were in critical limb ischemia. CONCLUSIONS: Our data indicate that selective stenting of the SFA after suboptimal balloon angioplasty results in intermediate patency rates similar to that reported for primarily successful PTA, thereby supporting the widely accepted policy of selective stenting as a rescue procedure after unsuccessful balloon angioplasty.     

“Trans‐collateral” angioplasty for a challenging chronic total occlusion of the tibial vessels: A novel approach to percutaneous revascularization in critical lower limb ischemia

Arterial revascularization by means of percutaneous transluminal angioplasty (PTA) is a mainstay in the management of patients with peripheral artery disease and critical limb ischemia (CLI). However, when employing standard approaches, PTA of below‐the‐knee arteries may fail in up to 20% of cases. In the present article, we report a novel interventional strategy, the “transcollateral” angioplasty approach, which we successfully employed in a patient with critical lower limb ischemia and a challenging total infrapopliteal occlusion. This technique may probably increase success rates of PTA in very challenging total occlusions of below‐the‐knee arteries (e.g., those lacking a proximal occlusion stump). The tips pertinent to this case are illustrated, including the need to accurately choose appropriate guidewires and balloons, and the identification of the most appropriate collateral pathway. © 2008 Wiley‐Liss, Inc.     

Assessment of 2-Year Mortality With Use of Drug-Coated Devices in Femoropopliteal Disease: A Real-World Experience From the Bronx,New York

The use of drug-coated devices (DCD) in peripheral arterial disease (PAD) intervention continues to remain controversial after a recent meta-analysis raised concerns of higher late mortality outcome with the use of these devices. Given this, there is need for more data with regards to the late mortality outcome with DCD use. We sought to assess the 2-year mortality outcome in patients with PAD treated with DCD in an inner-city public hospital that mainly serves patients of lower socio-economic status.MethodsThis was an observational study of consecutive patients with femoropopliteal arterial disease who had revascularization procedures from 2014 to 2018 at Jacobi Medical Center and were followed for 2 years. Patients were classified into DCD and non-drug-coated (nDCD) groups based on the device used at the index procedure. The primary endpoint was 2-year mortality. Propensity cohort matching was applied. A multivariate Cox regression model was used to identify baseline variables associated with 2-year mortality.Results152 patients were included in this analysis (DCD group = 83, nDCD group =69). No significant difference in mortality between the two groups was identified at 2 years after propensity score matching with replacement (DCD: HR 0.72; 95% CI 0.30–1.71; p = 0.457). Patients that had revascularization because of intermittent claudication had lower mortality at 2 years compared to patients with critical limb ischemia as procedure indication (HR 0.18; 95% CI 0.04–0.82; p = 0.026).ConclusionsThis propensity score matched study revealed no difference in 2-year mortality between patients treated with DCD compared to patients treated with nDCD.     

Post-irradiation axillo-subclavian arteriopathy: surgical revascularization

Post-irradiation axillo-subclavian arteriopathy can develop 6 months to 20 years after radiotherapy. Incidence estimated from duplex scan screening is about 30%, half of the cases having no hemodynamic significance. In our experience, asymptomatic lesions are the most common. Nevertheless, we have observed since 1978, 38 symptomatic patients including 23 with either acute ischemia (8 patients), or chronic ischemia (15 patients) requiring revascularization. We used an endovascular approach in 8 and open surgery in 15. A bypass graft was performed in 13 patients, using a vein (8 patients) rather than a prosthesis (5 patients), implanted in healthy territory, proximally or in the common carotid (11 patients) or the proximal subclavian (2 patients), and distally in the axillary artery (5 patients) or the brachial artery (8 patients). One venous bypass became occluded postoperatively. The other bypasses remained patent during follow-up of over 10 years. There of the five prosthetic bypassess gradually failed without recurrence of critical ischemia. Other revascularization procedures included endarterectomy and thrombectomy. In the long term, functional prognosis mainly depended on the frequently associated involvement of the plexus in the post-irradiation changes, which, together with the revascularization procedure, also required neurolysis in 11 patients, two omental covers and a free musculocutaneous transfer in 9 patients.     

Recanalization of native superficial femoral artery chronic total occlusion after failed femoropopliteal bypass in patients with critical limb ischemia

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.