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Limb ischemia, acute [keywords]
- Long-term effects of Combat Ready Clamp application to control junctional hemorrhage in swine. [Journal Article]
- J Trauma Acute Care Surg 2014 Sep; 77(3 Suppl 2):S101-8.
Groin application of Combat Ready Clamp (CRoC) in pigs elicits an acute inflammation in underlying ischemic tissues. This study examined functional recovery of pigs' hind leg(s) following 2 hours of CRoC application.Left femoral arteries were isolated and injured in anesthetized pigs. Following 25% hemorrhage, CRoC was applied on the inguen for 2 hours (n = 6), and wounds were covered with combat gauze (CG). Bleeding was treated in the control animals (n = 5) with CG only. Next, CRoC and CG were removed, arteries were repaired and reflowed, and animals were recovered. The legs' mobility was scored daily, and their neuromuscular functions were measured on Days 7 and 14. Computed tomographic angiography and blood analysis were performed on Days 0, 2, 7, and 14. Pigs were then euthanized, and tissues were collected for histology. Umbilicus application of CRoC was also tested in four pilot experiments.Inguinal application of CRoC with 524 ± 12 mm Hg pressure occluded iliac arteries and collateral circulation. Following surgical repair, blood flow to the arteries was restored, and five of six CRoC-applied legs recovered full mobility within 9 days. Control-treated legs recovered full function in 3 days (p = 0.001). At 2 weeks, muscle strength of CRoC-applied legs was diminished (p < 0.05 vs. baselines or controls). Injury biomarkers in the CRoC group increased severalfold compared with the controls on Day 2 but returned to baseline afterward. Histologic changes were mostly mild and indicative of ischemia in the CRoC group. Umbilical application of CRoC required higher pressure (625 ± 8 mm Hg) and caused gross ischemic necrosis of lumbar muscles with significant disabilities.Two-hour inguinal application of CRoC caused mild and reversible ischemic injuries, which delayed full recovery of the limb function by a few days. In contrast, 2-hour umbilicus application of CRoC resulted in extensive muscle necrosis with functional disabilities. While CRoC seems safe and effective for inguinal application, other tourniquets should be evaluated for treating bilateral junctional bleeding.
- [Acute limb ischaemia during myocardial infarction]. [Journal Article]
- Kardiol Pol 2014; 72(8):757.
- Clinical outcomes and cost-effectiveness of initial treatment strategies for nonembolic acute limb ischemia in real-life clinical settings. [JOURNAL ARTICLE]
- J Vasc Surg 2014 Aug 22.
The optimal initial treatment for patients with acute limb ischemia (ALI) remains undefined. Although clinical outcome data are inconsistent, catheter-directed thrombolysis (CDT) with tissue plasminogen activator is increasingly used. Patient-level analysis combining clinical and economic data in a real-life setting is lacking. This study compared clinical outcomes and cost-effectiveness of initial treatment strategies for nonembolic ALI using real-life patient-level data.Medical records and data for hospital costs were analyzed for nonembolic ALI patients treated in four hospitals over 3 years. A cost-effectiveness analysis was performed using a decision tree analytic model. All costs were valued based on cost-to-charge ratios.In 205 patients, initial treatments were CDT alone in 68 or with angioplasty in 16, open surgery in 60, endovascular in 33, and hybrid in 28. Although clinical outcomes did not differ significantly among the groups, reintervention rates during hospital stay, readmission rates, and costs were highest in the CDT group. Reintervention was required in 62% of patients after CDT compared with 7% after open surgery, and 16% of the CDT patients needed more than one reintervention. The mean total hospital cost was $34,800 per patient in CDT group compared with $10,677 in open surgery group.In this real-life study, initial treatment of nonembolic ALI with currently available CDT options was associated with greater health care resource consumption and cost compared with other initial treatment options.
- Do thrombotic events during endovascular interventions lead to poorer outcomes in patients with severe limb ischemia? [JOURNAL ARTICLE]
- Vascular 2014 Aug 19.
Intra-procedural acute thrombosis (IPAT) is a complication of endovascular procedures. We aim to identify risk factors for IPAT and compare the outcomes of patients with or without IPAT.Paired T test and χ(2) test were used to identify risk factors and short-term outcomes. Kaplan-Meier survival analysis was used for mid-term outcomes.A total of 228 procedures were performed with 21 IPAT events (9.21%). The odds ratio of Indian patients developing IPAT was 2.8x (95% CI 1.1-7.6). Patients with in-stent occlusion or prior IPAT were 5.6x (95% CI 1.3-24.2) and 5.6x (95% CI 1.3-24.4) more likely to develop an IPAT event. Patients without IPAT had significantly more improvement in mean runoff score (-1.15 ± 1.31, p < 0.01). The odds of patients with IPAT requiring subsequent endovascular intervention and arterial bypass surgery were 4.2x (95% CI 1.6-10.7) and 7.1x (95% CI 1.9-27.0). There was no significant Kaplan-Meier estimated overall survival or amputation-free survival difference between patients with or without IPAT event.Indian ethnicity, in-stent occlusion and previous IPAT were associated with higher risk of IPAT. Even after successful endovascular salvage, patients with IPATs were more likely to require secondary revascularization procedure. Patients with IPATs had no decrease in overall survival or amputation-free survival.
- Open fenestration for complicated acute aortic B dissection. [Journal Article, Review]
- Ann Cardiothorac Surg 2014 Jul; 3(4):418-22.
Acute type B aortic dissection (ABAD) is a serious cardiovascular emergency in which morbidity and mortality are often related to the presence of complications at clinical presentation. Visceral, renal, and limb ischemia occur in up to 30% of patients with ABAD and are associated with higher in-hospital mortality. The aim of the open fenestration is to resolve the malperfusion by creating a single aortic lumen at the suprarenal or infrarenal level. This surgical procedure is less invasive than total aortic replacement, thus not requiring extracorporeal support and allowing preservation of the intercostal arteries, which results in decreased risk of paraplegia. Surgical aortic fenestration represents an effective and durable option for treating ischemic complications of ABAD, particularly for patients with no aortic dilatation. In the current endovascular era, this open technique serves as an alternative option in case of contraindications or failure of endovascular management of complicated ABAD.
- Lower limb malperfusion in type B aortic dissection: a systematic review. [Journal Article, Review]
- Ann Cardiothorac Surg 2014 Jul; 3(4):351-67.
Lower limb malperfusion (LLM) syndrome occurs in up to 40% of complicated type B aortic dissections (TBAD) and in up to 71% of TBAD with malperfusion syndrome. This syndrome is associated with higher 30-day mortality. The aim of this systematic review was to provide clinical and procedural data of patients with LLM syndrome secondary to TBAD.The PubMed database was systematically searched from January 2000 to June 2014 for English-language publications reporting on demographic data of patients with LLM secondary to TBAD.A total of 29 papers were included (10 original articles and 19 case reports), reporting on a total of 138 patients (mean age =58±12 years; male =87%). Lower limb complications developed in acute and chronic TBAD in 134 (97%) and 4 (3%) cases, respectively. LLM presented with acute limb ischemia in 120 (87%) patients. Bilateral clinical presentation occurred in 56% (40/72) of cases. LLM was the only clinically detected malperfusion in 52% of cases (44/84). In 40% (35/84) and 25% (21/84) of cases, LLM was clinically associated with renal and visceral malperfusion, respectively. Radiological imaging showed renal, celiac trunk and superior mesenteric artery involvement in 53% (47/88), 31% (27/88) and 34% (30/88) of cases, respectively. Medical, surgical and endovascular treatments were performed in 22 (16%), 51 (37%) and 65 (47%) patients, respectively. Thirty-day morbidity was 31% (13/42) and 46% (6/13) following surgical and endovascular treatment, respectively. Thirty-day mortality was 14% (5/36) and 8% (2/26) following surgical and endovascular treatment, respectively.LLM syndrome secondary to TBAD usually developed during the acute phase and, in most cases, presented with acute limb ischemia. Bilateral clinical presentation occurred in more than half of cases. Renal and visceral malperfusion were frequently associated with lower limb flow reduction but LLM was the only clinically detected malperfusion in more than half of patients. Surgical fenestration was burdened with significant complication rates and 30-day mortality. Endovascular procedures showed lower mortality but complication rates remained high.
- IMAGING DIAGNOSIS-ACUTE MESENTERIC ISCHEMIA ASSOCIATED WITH HYPERTROPHIC CARDIOMYOPATHY IN A CAT. [JOURNAL ARTICLE]
- Vet Radiol Ultrasound 2014 Aug 14.
A middle-aged cat was presented with vomiting, diarrhea, and pelvic limb paresis. Radiography showed cardiomegaly, interstitial pulmonary infiltration, distended intestinal loops, and portal venous gas. Hypertrophic cardiomyopathy (HCM) was confirmed. On CT, thrombi were identified at the abdominal aorta, superior mesenteric artery, bilateral renal arteries, and cauda vena cava at the level of the iliac vein bifurcation. Dilated and gas-filled loops of bowel with a "paper thin wall" were observed on CT images and were considered indicative of necrotic bowel. This case report describes the CT findings of acute mesenteric ischemia associated with HCM in a cat.
- Forearm compartment syndrome caused by reperfusion injury. [Journal Article]
- Case Rep Vasc Med 2014.:931410.
Compartment syndrome is commonly seen following lower extremity ischemia. However, upper extremities' compartment syndrome, especially after any vascular surgical procedures, is infrequent. Herein we report a case of an acute forearm compartment syndrome that was developed after delayed brachial artery embolectomy.
- Cystic Adventitial Disease of the Common Femoral Artery Presenting with Acute Limb Ischemia. [JOURNAL ARTICLE]
- Ann Vasc Surg 2014 Aug 7.
Cystic adventitial disease (CAD) is a recognized cause of chronic lower limb ischemia. We present a case of CAD presenting as acute lower limb ischemia. A 54-year-old woman presented with a 48-hr history of sudden-onset right leg and foot pain associated with paresthesia and weakness. Duplex ultrasound and computed tomography angiogram showed acute occlusion of the common, superficial, and profunda femoral arteries. On surgical exploration, a mucinous cystic structure was found occluding the common femoral artery (CFA), which was later confirmed on histology as CAD. Because of the extent of the cyst, we treated this with an interposition graft, and the patient initially made a good recovery. However, 2 months later, she presented again with acute lower limb ischemia, and investigation and surgical exploration confirmed further cystic degeneration of the remaining part of the CFA. This case highlights a rare presentation and shows the importance of a high index of suspicion when investigating and treating young patients with lower limb symptoms, particularly when interpreting imaging.
- Acute limb ischemia and transesophageal echocardiography: making a case. [Journal Article]
- J Cardiothorac Vasc Anesth 2014 Aug; 28(4):1176-7.