-
Surgery Mar 2023Mechanical circulatory support effectively treats adult cardiogenic shock. Whereas cardiogenic shock confers high mortality, acute limb ischemia is a known complication...
Peripherally inserted concomitant surgical right and left ventricular support, the Propella, is associated with low rates of limb ischemia, with mortality comparable with peripheral venoarterial extracorporeal membrane oxygenation.
BACKGROUND
Mechanical circulatory support effectively treats adult cardiogenic shock. Whereas cardiogenic shock confers high mortality, acute limb ischemia is a known complication of mechanical circulatory support that confers significant morbidity. We compared our novel approach to peripheral mechanical circulatory support with a conventional femoral approach, with a focus on the incidence of acute limb ischemia.
METHODS
This was a retrospective cohort study of patients treated with mechanical circulatory support between January 1, 2015 and December 5, 2021 at our institution. Patients receiving any femoral peripheral venoarterial extracorporeal membrane oxygenation were compared with those receiving minimally invasive, peripherally inserted, concomitant right and left ventricular assist devices. These included the Impella 5.0 (Abiomed, Danvers, MA) left ventricular assist device and the ProtekDuo (LivaNova, London, UK) right ventricular assist device used concomitantly (Propella) approach. The primary outcome was incidence of acute limb ischemia. The baseline patient characteristics, hemodynamic data, and post-mechanical circulatory support outcomes were collected. Fisher exact test and Wilcoxon rank sum test was used for the categorical and continuous variables, respectively. Kaplan-Meier curves and log-rank test were used to estimate overall survival probabilities and survival experience, respectively.
RESULTS
Fifty patients were treated with mechanical circulatory support at our institution for cardiogenic shock, with 13 patients supported with the novel Propella strategy and 37 with peripheral venoarterial extracorporeal membrane oxygenation. The baseline characteristics, including patient organ function and medical comorbidities, were similar among the groups. Nine patients suffered mortality in ≤48 hours of mechanical circulatory support initiation and were excluded. Twenty patients (69%) suffered acute limb ischemia in the peripheral venoarterial extracorporeal membrane oxygenation group; 0 patients receiving Propella suffered acute limb ischemia (P < .001). The percentages of patients surviving to discharge in peripheral venoarterial extracorporeal membrane oxygenation and Propella groups were 24% and 69%, respectively (P = .007).
CONCLUSION
Patients treated with the Propella experienced a lower incidence of acute limb ischemia compared with patients treated with peripheral venoarterial extracorporeal membrane oxygenation.
Topics: Adult; Humans; Shock, Cardiogenic; Retrospective Studies; Extracorporeal Membrane Oxygenation; Ischemia; Heart-Assist Devices
PubMed: 36435648
DOI: 10.1016/j.surg.2022.10.007 -
British Journal of Hospital Medicine... May 2022Aneurysms are associated with significant complications if not diagnosed and managed appropriately. Popliteal arterial aneurysms are the most common peripheral aneurysm,...
Aneurysms are associated with significant complications if not diagnosed and managed appropriately. Popliteal arterial aneurysms are the most common peripheral aneurysm, and can cause pain, nerve compression, ischaemia and limb loss. Vascular surgery is an emerging specialty under the remit of general surgery, with the primary objectives of preventing death and limb loss. This article summarises the epidemiology, investigation and management of popliteal arterial aneurysms for vascular and non-vascular trainees.
Topics: Aneurysm; Humans; Ischemia; Popliteal Artery
PubMed: 35653317
DOI: 10.12968/hmed.2021.0572 -
Age and Ageing Jun 2024Peripheral artery disease (PAD) is the lower limb manifestation of systemic atherosclerotic disease. PAD may initially present with symptoms of intermittent... (Review)
Review
Peripheral artery disease (PAD) is the lower limb manifestation of systemic atherosclerotic disease. PAD may initially present with symptoms of intermittent claudication, whilst chronic limb-threatening ischaemia (CLTI), the end stage of PAD, presents with rest pain and/or tissue loss. PAD is an age-related condition present in over 10% of those aged ≥65 in high-income countries. Guidelines regarding definition, diagnosis and staging of PAD and CLTI have been updated to reflect the changing patterns and presentations of disease given the increasing prevalence of diabetes. Recent research has changed guidelines on optimal medical therapy, with low-dose anticoagulant plus aspirin recommended in some patients. Recently published randomised trials highlight where bypass-first or endovascular-first approaches may be optimal in infra-inguinal disease. New techniques in endovascular surgery have increased minimally invasive options for ever more complex disease. Increasing recognition has been given to the complexity of patients with CLTI where a high prevalence of both frailty and cognitive impairment are present and a significant burden of multi-morbidity and polypharmacy. Despite advances in minimally invasive revascularisation techniques and reduction in amputation incidence, survival remains poor for many with CLTI. Shared decision-making is essential, and conservative management is often appropriate for older patients. There is emerging evidence of the benefit of specialist geriatric team input in the perioperative management of older patients undergoing surgery for CLTI. Recent UK guidelines now recommend screening for frailty, cognitive impairment and delirium in older vascular surgery patients as well as recommending all vascular surgery services have support and input from specialist geriatrics teams.
Topics: Humans; Peripheral Arterial Disease; Aged; Endovascular Procedures; Risk Factors; Chronic Limb-Threatening Ischemia; Vascular Surgical Procedures; Age Factors; Practice Guidelines as Topic
PubMed: 38877714
DOI: 10.1093/ageing/afae114 -
Journal of Vascular Surgery May 2010A 2005 interim analysis of the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial showed that in patients with severe lower limb ischemia (SLI; rest... (Comparative Study)
Comparative Study Randomized Controlled Trial
Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: An intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy.
BACKGROUND
A 2005 interim analysis of the Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial showed that in patients with severe lower limb ischemia (SLI; rest pain, ulceration, gangrene) due to infrainguinal disease, bypass surgery (BSX)-first and balloon angioplasty (BAP)-first revascularization strategies led to similar short-term clinical outcomes, although BSX was about one-third more expensive and morbidity was higher. We have monitored patients for a further 2.5 years and now report a final intention-to-treat (ITT) analysis of amputation-free survival (AFS) and overall survival (OS).
METHODS
Of 452 enrolled patients in 27 United Kingdom hospitals, 228 were randomized to a BSX-first and 224 to a BAP-first revascularization strategy. All patients were monitored for 3 years and more than half for >5 years.
RESULTS
At the end of follow-up, 250 patients were dead (56%), 168 (38%) were alive without amputation, and 30 (7%) were alive with amputation. Four were lost to follow-up. AFS and OS did not differ between randomized treatments during the follow-up. For those patients surviving 2 years from randomization, however, BSX-first revascularization was associated with a reduced hazard ratio (HR) for subsequent AFS of 0.85 (95% confidence interval [CI], 0.5-1.07; P = .108) and for subsequent OS of 0.61 (95% CI, 0.50-0.75; P = .009) in an adjusted, time-dependent Cox proportional hazards model. For those patients who survived for 2 years after randomization, initial randomization to a BSX-first revascularization strategy was associated with an increase in subsequent restricted mean overall survival of 7.3 months (95% CI, 1.2-13.4 months, P = .02) and an increase in restricted mean AFS of 5.9 months (95% CI, 0.2-12.0 months, P = .06) during the subsequent mean follow-up of 3.1 years (range, 1-5.7 years).
CONCLUSIONS
Overall, there was no significant difference in AFS or OS between the two strategies. However, for those patients who survived for at least 2 years after randomization, a BSX-first revascularization strategy was associated with a significant increase in subsequent OS and a trend towards improved AFS.
Topics: Aged; Aged, 80 and over; Amputation, Surgical; Angioplasty, Balloon; Blood Vessel Prosthesis Implantation; Constriction, Pathologic; Female; Humans; Ischemia; Lower Extremity; Male; Middle Aged; Peripheral Vascular Diseases; Proportional Hazards Models; Prospective Studies; Radiography; Reoperation; Risk Assessment; Risk Factors; Saphenous Vein; Severity of Illness Index; Survival Analysis; Time Factors; Treatment Outcome; United Kingdom; Vascular Surgical Procedures
PubMed: 20435258
DOI: 10.1016/j.jvs.2010.01.073 -
Internal Medicine Journal Feb 2010Limb Ischaemia is an exceptional complication of catecholamine toxicity caused by a phaeochromocytoma. We present a middle-aged female patient with severe subacute... (Review)
Review
Limb Ischaemia is an exceptional complication of catecholamine toxicity caused by a phaeochromocytoma. We present a middle-aged female patient with severe subacute peripheral ishaemia, gangrene and eventual amputation of all four distal limbs due to a large non-metastatic left adrenal gland phaeochromocytoma and summarise the available literature concerning previously reported cases.
Topics: Adrenal Gland Neoplasms; Aged; Female; Foot; Hand; Humans; Ischemia; Nose; Pheochromocytoma
PubMed: 20446956
DOI: 10.1111/j.1445-5994.2009.02095.x -
European Journal of Vascular and... Nov 2020
Topics: Amputation, Surgical; Cohort Studies; Humans; Ischemia; Peripheral Vascular Diseases; United Kingdom
PubMed: 32978051
DOI: 10.1016/j.ejvs.2020.08.029 -
Annals of the Royal College of Surgeons... Jan 2002Peripheral angioplasty is increasingly the first choice intervention in patients with peripheral vascular disease. The aim of the current study was to audit...
BACKGROUND
Peripheral angioplasty is increasingly the first choice intervention in patients with peripheral vascular disease. The aim of the current study was to audit prospectively all major complications, especially the requirement for emergency surgical intervention.
PATIENTS AND METHODS
A prospective audit of outcome after peripheral angioplasty in 988 patients undergoing 1377 interventional procedures between 1 October 1995 and 30 September 1998 at which 1619 vessel segments were angioplastied.
RESULTS
Major medical morbidity (bronchopneumonia, stroke, renal failure, myocardial infarction) complicated 33/1377 procedures (2.4%). Emergency surgical intervention was required after 31/1377 procedures (2.3%) with the commonest aetiologies being acute limb ischaemia and haemorrhagic complications. The amputation rate following angioplasty was 0.6% and no patient presenting with claudication or graft complications underwent amputation. The amputation rate following angioplasty for critical limb ischaemia was 2.2%. Overall, the risk of death and/or major medical complication and/or requiring emergency surgical intervention was 3.5%. The rate of complications was no different for subintimal as opposed to transluminal angioplasties.
CONCLUSIONS
Peripheral angioplasty is associated with a low risk of major medical and surgical complications.
Topics: Amputation, Surgical; Angioplasty; Bronchopneumonia; Emergencies; Female; Hematoma; Hemorrhage; Humans; Intermittent Claudication; Ischemia; Leg; Male; Medical Audit; Middle Aged; Peripheral Vascular Diseases; Postoperative Complications; Prospective Studies; Reoperation; Salvage Therapy; Treatment Outcome
PubMed: 11892730
DOI: No ID Found -
Hamostaseologie Jan 2009Critical limb ischaemia (CLI) is a manifestation of peripheral arterial disease (PAD) that describes patients with chronic ischaemic rest pain, or patients with... (Review)
Review
Critical limb ischaemia (CLI) is a manifestation of peripheral arterial disease (PAD) that describes patients with chronic ischaemic rest pain, or patients with ischaemic skin lesions, either ulcers or gangrene. The clinical diagnosis of CLI should be confirmed by haemodynamic parameters such as the ankle- or toe systolic pressure. The estimated annual incidence of CLI ranges between 500 and 1 000 new cases per 1 million, with diabetes being the most important risk factor. CLI is also a marker for mostly generalized and severe atherosclerosis, and therefore the prognosis of patients is poor concerning overall survival. The primary goals of treatment in patients with CLI are to relieve ischaemic pain, heal ulcers, prevent limb loss, improve patient function and quality of life and prolong overall survival. Any kind of revascularization should be done whenever technically possible, and therefore most patients should be referred to a vascular center. Furthermore, in patients with CLI a multidisciplinary approach is recommended to control pain, cardiovascular risk factors and other co-morbid disease. In patients with CLI not eligible for arterial revascularization, prostanoids are the only vasoactive drugs with proven efficacy. The safety and efficacy of the various forms of therapeutic angiogenesis still have to be proven before one can conclude on its role as an additional limb saving strategy.
Topics: Blood Pressure; Disease Progression; Foot; Humans; Hypertension; Ischemia; Leg; Neovascularization, Physiologic; Peripheral Vascular Diseases; Platelet Aggregation Inhibitors; Risk Factors; Smoking Cessation; Spinal Cord; Vascular Surgical Procedures
PubMed: 19151858
DOI: No ID Found -
VASA. Zeitschrift Fur Gefasskrankheiten Mar 2017The prevalence of peripheral artery disease (PAD) is increasing worldwide and is strongly age-related, affecting about 20 % of Germans over 70 years of age. Recent... (Review)
Review
The prevalence of peripheral artery disease (PAD) is increasing worldwide and is strongly age-related, affecting about 20 % of Germans over 70 years of age. Recent advances in endovascular and surgical techniques as well as clinical study results on comparative treatment methods strengthened the need for a comprehensive review of the published evidence for diagnosis, management, and prevention of PAD. The interdisciplinary guideline exclusively covers distal aorta and atherosclerotic lower extremity artery disease. A systematic literature review and formal consensus finding process, including delegated members of 22 medical societies and two patient self-support organisations were conducted and supervised by the Association of Scientific Medical Societies in Germany, AWMF. Three levels of recommendation were defined, A = "is recommended/indicated", B = "should be considered", C = "may be considered", means agreement of expert opinions due to lack of evidence. Altogether 294 articles, including 34 systematic reviews and 98 RCTs have been analysed. The key diagnostic tools and treatment basics have been defined. In patients with intermittent claudication endovascular and/or surgical techniques are treatment options depending on appropriate individual morphology and patient preference. In critical limb ischaemia, revascularisation without delay by means of the most appropriate technique is key. If possible and reasonable, endovascular procedures should be applied first. The TASC classification is no longer recommended as the base of therapeutic decision process due to advances in endovascular techniques and new crural therapeutic options. Limited new data on rehabilitation and follow-up therapies have been integrated. The article summarises major new aspects of PAD treatment from the updated German Guidelines for Diagnosis and Treatment of PAD. Limited scientific evidence still calls for randomised clinical trials to close the present gap of evidence.
Topics: Aged; Cardiovascular Agents; Consensus; Critical Illness; Endovascular Procedures; Evidence-Based Medicine; Female; Germany; Humans; Intermittent Claudication; Ischemia; Male; Peripheral Arterial Disease; Risk Reduction Behavior; Vascular Surgical Procedures
PubMed: 28128018
DOI: 10.1024/0301-1526/a000603 -
The British Journal of Surgery Mar 2023
Topics: Humans; Chronic Disease; Chronic Limb-Threatening Ischemia; Ischemia; Peripheral Arterial Disease; Retrospective Studies; Risk Factors; Treatment Outcome
PubMed: 36638367
DOI: 10.1093/bjs/znac465