Increased limb salvage. Distal tibial/peroneal artery thrombectomy/embolectomy in acute lower extremity ischemia

Fifty-five acutely ischemic lower extremities, in 35 patients, which remained ischemic after standard thrombectomy/embolectomy techniques were further treated with distal tibial/peroneal thrombectomy/embolectomy by ankle level arteriotomy to increase limb salvage. A total of 84 infrapopliteal arteries were explored and thromboembolectomy performed in 79. The precipitating ischemic event was arterial embolus in 38 per cent, arterial thrombus in 60 per cent, and trauma in 2 per cent of the cases. There were 16 female and 19 male patients. Additional bypass grafting was used in 18 per cent of extremities. The limb salvage rate was 91 per cent in this select "tibial/peroneal" group. This technique salvaged 50 limbs that otherwise would have required major amputation. The addition of this technique changed the potential limb salvage rate from 76 per cent of the entire 199 lower extremities treated during this period to an actual limb salvage rate of 97 per cent. Operative mortality was 16 per cent in this selected group with an overall mortality of 6 per cent for all patients with acutely ischemic lower limbs. A mean patient follow-up of 32 months (range 12 to 72 months) identified only three late amputations, demonstrating that distal tibial/peroneal thrombectomy/embolectomy is a durable procedure. It is a technically easy means of promoting limb salvage in the acutely ischemic limb which either 1) remains ischemic after standard transinguinal iliofemoral thromboembolectomy, or 2) is secondary to infrapopliteal artery occlusion. It allows successful thromboembolectomy of acutely occluded infrapopliteal arteries without distal popliteal arteriotomy. These techniques should be within the armamentarium of all surgeons dealing with acute lower extremity ischemia.     

Rotarex机械血栓清除术治疗股腘动脉血栓所致急性下肢缺血

目的观察Rotarex经皮机械血栓清除术(PMT)治疗股腘动脉血栓形成所致急性下肢缺血(ALI)的有效性及安全性。方法回顾性分析22例股腘动脉血栓致ALI患者,均采用Rotarex装置行PMT,观察治疗效果及并发症。结果 22例均顺利完成PMT;其中4例辅以经导管接触性溶栓治疗,17例联合球囊扩张术,12例行支架植入术。术后股腘动脉均再通,技术成功率100%,踝肱指数较术前显著增加(P0.05)。22例中,21例临床有效,术后Rutherford分级均改善;1例临床无效,3周后接受坏死足趾切除术。PMT术中发生远端动脉栓塞1例,血管夹层1例。1例术后6个月股浅动脉支架内再闭塞,1例术后9个月下肢动脉血栓复发。结论采用Rotarex装置行PMT治疗股腘动脉血栓所致ALI疗效好,安全性高。     

Endovascular intervention for tibial artery occlusive disease in patients with critical limb ischemia

Surgical bypass has traditionally been the gold standard for treating critical limb ischemia caused by isolated infrapopliteal arterial disease (IP CLI). However, as endovascular techniques continue to progress, they are increasingly applied to this patient population, especially to the high-risk surgical cohort or patients with limited surgical options. This enthusiasm to employ endovascular interventions in IP CLI is accompanied by persistent controversies, as demonstrated in the recent literature. Percutaneous transluminal balloon angioplasty has been the predominant endovascular intervention applied to treat IP CLI and recent literature supports its role. The durability of percutaneous transluminal balloon angioplasty is limited, and thus this intervention is recommended for high-risk patients with limited life expectancy. Bare-metal stents for IP CLI currently do not have supportive data to warrant their use as a primary treatment. Newer drug-eluting stents improve patency and prevent restenosis, but they do not significantly improve patient clinical status compared with bare-metal stents alone. Drug-coated balloons are still relatively new tools in this arena and evidence of their safety and clear efficacy are still lacking. The data on atherectomy, in all of its forms, for IP CLI are overall variable, without any clear benefit to justify its increased complication risks and costs over other modalities. Use of retrograde tibial/pedal access for treating IP CLI as a viable alternative to antegrade access and treatment from a totally retrograde approach has recently been described. Level I evidence to aid in clarifying the true efficacy for each of these endovascular modalities is greatly needed. As we await these data, we must remember that, as with any arterial intervention, proper patient selection is extremely important and the intervention, whether endovascular or open surgical repair, should be tailored to the individual patient’s anatomy and disease characteristics.     

经皮机械性血栓清除联合导管溶栓与单纯导管溶栓治疗急性下肢缺血的疗效比较

目的比较PMT联合CDT与单纯CDT治疗急性下肢缺血的临床疗效。方法回顾性分析2017年1月至2018年12月苏州大学附属第一医院收治的64例急性下肢缺血患者的临床资料,其中24例行PMT联合CDT治疗(PMT组),40例行单纯CDT治疗(CDT组)。比较两组手术成功率、尿激酶用量、手术时间、溶栓时间、住院时间、住院期间并发症发生率和术后30 d内截肢率、再次手术率及死亡率。结果两组手术均取得成功,技术成功率为100%;PMT组和CDT组的尿激酶用量分别为(56.67±8.16)万U和(106.50±47.56)万U,手术时间分别为(103.33±25.57)min和(72.13±25.74)min,溶栓时间分别为(24.96±12.52)h和(61.20±29.24)h,住院时间分别为(7.13±2.52)d和(9.35±2.65)d,差异均有统计学意义(P<0.01)。两组住院期间并发症发生率(16.7%vs 17.5%)、术后30 d内截肢率(12.5%vs15.0%)、再次手术率(4.2%vs 7.5%)及死亡率(8.3%vs 2.5%)差异均无统计学意义(P>0.05)。不同缺血时间患者的缺血改善情况,两组比较差异均无统计学意义(P>0.05)。结论采取PMT联合CDT治疗急性下肢缺血患者在手术疗效、并发症发生情况结果和单纯CDT相似,但可降低溶栓药物用量、缩短溶栓时间和住院时间。     

Distal posterior tibial artery pseudoaneurysm after fracture calcaneous

Here we report a case of pseudoaneurysm of distal posterior tibial artery following closed fracture of calcaneous. Association of pseudoaneurysm of posterior tibial artery with fracture of calcaneous is extremely uncommon. It is always suggested that pseudoaneurysm be treated by reconstruction, but here we present the case treated by ligation, obliteration and excision as it was situated distally and the plantar arch circulation was maintained. The purpose of this case report is to bring attention to this complication of vascular trauma, which may cause delayed symptoms long time after the injury as well as the rare incidence of posterior tibial artery involvement with fracture calcaneous.     

Endovascular management of acute critical ischemia secondary to blunt tibial artery injury

We report a case of acute limb-threatening ischemia from blunt traumatic tibial arterial disruption managed with endoluminal techniques. An otherwise healthy 37-year-old man involved in a motorcycle crash sustained a compound fracture of his right tibia and fibula. Arterial insufficiency developed after surgical reduction of the orthopedic injuries that warranted selective angiography of the involved extremity. This demonstrated complete occlusion of the infrageniculate circulation at the level of the ankle. Recanalization of the posterior tibial artery was achieved by using coronary balloon-expandable stents, thereby reestablishing in-line flow to the foot. Clinical and noninvasive surveillance at 2 years confirmed patency of the recanalized artery with the absence of any ischemic symptoms. Arterial reconstruction of the infrapopliteal arterial tree poses a formidable challenge in the setting of blunt trauma. Recent improvements in endovascular skills, endoluminal technology, and imaging capabilities have allowed percutaneous reconstruction of challenging arterial pathology. Endovascular treatment of blunt tibial injuries is an alternative to complex open reconstructions. These patients require close long-term postoperative surveillance because the durability of such a repair remains unknown.     

Acute ischemia of the limb in a newborn treated successfully by thrombectomy

A seven day old dehydrated male infant was found to have acute ischemia of the leg due to acute thrombotic occlusion of an external iliac, common and superficial femoral, and popliteal arteries. Early thrombectomy and arterioplasty resulted in complete remission of ischemia. Our success with direct vascular surgery prompts us to recommend this form of treatment in preventing neonatal gangrene. To our knowledge, this is the first report of successful thrombectomy in a newborn infant.     

急性肢体缺血的治疗

目的 探讨急性肢体缺血的治疗方法 .方法 回顾性分析28例急性肢体缺血的临床资料.4例急性动脉栓塞者行急症取栓术,1例假性动脉瘤患者行假性动脉瘤切除及人工血管植入术,23例动脉闭塞症者采用取栓、血管旁路术、血管腔内治疗、截肢、单纯药物等治疗.结果 5例急性动脉栓塞及假性动脉瘤患者治疗成功,23例动脉闭塞症患者中,5例(21.7%)治疗成功,12例(52.2%)好转,6例(26.1%)无效,4例截肢(占动脉闭塞疾病的17.4%).无1例死亡.6～45个月随访中,另有5例截肢,死亡4例.结论 急性肢体缺血患者需根据病情选择合理的治疗策略,包括取栓及血管重建等,以达到挽救肢体和生命的目的 .     

Clinical effects of single or double tibial artery revascularization in critical limb ischemia patients with tissue loss

Objective

The achievement of single vessel inflow to the wound is an acceptable end point of peripheral vascular intervention for patients with critical limb ischemia (CLI) with tissue loss. However, CLI patients often have multitibial artery lesions. We evaluated the clinical effects of single or double tibial artery revascularization for CLI patients.

Endovascular management of acute limb ischemia

Despite major advances in pharmacologic and endovascular therapies, acute limb ischemia (ALI) continues to result in significant morbidity and mortality. The incidence of ALI may be as high as 13-17 cases per 100,000 people per year, with mortality rates approaching 18% in some series. This review will address the contemporary endovascular management of ALI encompassing pharmacologic and percutaneous interventional treatment strategies.