Acute limb ischemia (ALI) carries significant morbidity, and procedural adaptability is critical when standard endovascular therapies fail. We describe four cases of ALI in which the Artix Thrombectomy System resulted in successful revascularization after aspiration thrombectomy failed. Target limb salvage at 30 days was achieved in all patients. Thromboaspiration in Peripheral Ischemia 2/3 flow was achieved in all patients and 75% maintained primary patency at 30 days. There were no device related complications. These findings support Artix as a safe and effective rescue therapy for ALI and encourage future studies to investigate its utility as a first-line treatment.

Extracorporeal membrane oxygenation (ECMO) has become an increasingly vital intervention for patients with severe cardiac and respiratory failure, significantly improving short-term survival rates. However, there is growing recognition of the importance of long-term outcomes, including health-related quality of life (HRQoL), functional recovery, and psychological well-being. This narrative review synthesizes clinical studies, systematic reviews, and cohort analyses from the past 20 years using PubMed and Google Scholar, focusing on adult ECMO survivors. Studies consistently demonstrate that although many survivors achieve functional independence, a significant proportion experience persistent limitation. Common long-term sequelae include reduced physical capacity, depression, anxiety, cognitive impairment, and challenges in social reintegration such as returning into employment. Outcomes vary by ECMO modality: Veno venous (VV) ECMO survivors typically report better HRQoL than those receiving Veno arterial (VA) ECMO, although depression appears more prevalent among VV ECMO survivors. Significant complications including neurological injury, limb ischemia, and bleeding remain major contributors to morbidity, particularly in VA ECMO cohorts. The differences reflect variation in underlying disease and complication burden between the 2 modalities. Rehabilitation strategies emphasizing early physiotherapy, structured discharge planning, and comprehensive long-term follow-up are associated with improved functional and psychosocial outcomes. Despite rising survival, existing literature reveals considerable heterogeneity, a lack of standardized outcome measures, and limited prospective multicenter data. Future research should focus on innovations in ECMO circuit design, safer anticoagulation protocols, and the development of standardized rehabilitation pathways. Incorporating long-term functional, psychological, and social outcomes into ECMO care paradigms, is essential to move beyond survival towards meaningful recovery, ultimately optimizing quality of life for ECMO survivors.

Acute limb ischemia (ALI) attributable to mural thrombus in an abdominal aortic aneurysm (AAA) is a clinically relevant complication owing to its high mortality risk. We encountered a patient with a floating thrombus in an AAA, which caused ALI. Computed tomography revealed an AAA with irregular mural thrombi, along with left popliteal artery occlusion. We performed urgent thrombectomy followed by elective endovascular aneurysm repair without any major complications. The keys to this successful outcome were earlier extremity reperfusion and less invasive aortic repair.

Iatrogenic injuries related to resuscitative efforts and emergent vascular access can be life-threatening, particularly in critically ill patients with limited treatment options. We present a case of a patient who collapsed due to an acute ST-elevation myocardial infarction and underwent prolonged resuscitation, which was complicated by hepatic injury likely secondary to chest compressions and injury to the left common femoral artery (CFA) following multiple arterial line attempts. The patient was referred for an angiogram evaluation primarily for suspected hepatic injury. Conventional femoral access was not feasible, as the right groin was occupied by emergent venoarterial extracorporeal membrane oxygenation (VA-ECMO) cannulation, and a femoral compression device had been applied to the left groin following failed arterial access. Therefore, hepatic angiography was performed via left transradial access and demonstrated no active hemorrhage. Given the history of difficult arterial femoral access, further interrogation of the left iliofemoral system was undertaken, revealing multiple sites of active bleeding from the left CFA. Given the patient's clinical instability and poor candidacy for surgical repair, an endovascular approach was pursued. However, the available covered stent system could not be advanced to the target from the radial access due to length limitations, necessitating an alternative strategy. Retrograde pedal access was obtained, allowing successful treatment of the injured CFA segment with restoration of hemostasis and preservation of distal perfusion. The patient experienced no recurrent bleeding, limb ischemia, or need for reintervention during the hospitalization. This case highlighted the spectrum of resuscitation-related iatrogenic injuries and underscores the importance of adaptable endovascular strategies when conventional access routes are not feasible.

Acute limb ischemia (ALI) is a sudden decrease in lower limb arterial perfusion that poses a threat not only to limb viability but alsoto life and requires urgent evaluation and management. The etiology of ALI is broadly divided into embolism and thrombosis, along with various comorbidities. Severity and treatment strategy should be determined based on physical and image findings. Revascularization can be performed surgically (thromboembolectomy or bypass), endovascularly, or through a hybrid procedure. In all cases, it is important to conduct intraoperative angiography and perform the necessary additional procedures. A prompt response to myonephropathic metabolic syndrome or compartment syndrome during or after revascularization is also essential. ALI is a serious condition that requires emergency treatment, and it is important to be familiar with all treatment options, including surgical and endovascular treatments, fasciotomy, and primary limb amputation, and to promptly provide the best available initial treatment at each facility. (This is a translation of Jpn J Vasc Surg 2024; 33: 199-204.).

Acute limb ischemia (ALI) is a significant and potentially limb- and life-threatening complication associated with all temporary mechanical circulatory support devices inserted into the peripheral arteries. Device-related ALI is principally due to obstruction of antegrade blood flow by large-caliber vascular sheaths and cannulas, but several clinical and patient-specific factors may increase risk. Prevention of device-related ALI is key and is achieved by identification of patients at elevated risk, careful percutaneous arterial access for device deployment, selection of the smallest clinically appropriate device or cannula, regular clinical monitoring during device use by standard physical examination and additional tools, and device explant as soon as clinically feasible. Placement of a distal perfusion catheter is now common practice to maintain adequate limb perfusion during venoarterial extracorporeal membrane oxygenation use and may additionally be used to treat ALI due to intraaortic balloon pump or Impella CP. Integrating best practices and perfusion strategies is essential to mitigate ALI-related morbidity and improve outcomes for patients requiring percutaneous temporary mechanical hemodynamic support.

Background: Peripheral artery disease (PAD) impacts more than 200 million individuals globally. Despite its prevalence, management remains suboptimal, partly due to the lack of reliable blood-based biomarkers. The ankle-brachial index (ABI), the current gold-standard test for PAD, is limited by inter-operator variability, misinterpretation, and reduced accuracy in patients with diabetes. Fatty acid binding protein 3 (FABP3) has emerged as a potential biomarker for PAD; however, its prognostic performance relative to ABI remains unclear. This study compared FABP3 and ABI for predicting PAD outcomes using statistical and machine learning approaches. Methods: A total of 1001 participants were prospectively recruited, including 644 patients with PAD and 357 without PAD. The primary outcome was 2-year major adverse limb event (MALE), defined as a composite of vascular intervention, major amputation, or acute limb ischemia. At enrollment, plasma FABP3 was quantified using a validated multiplex immunoassay. Kaplan-Meier analysis of MALE-free survival was performed across pre-specified FABP3 tertiles (high [>3.55 ng/mL], moderate [1.55-3.55 ng/mL], and low [<1.55 ng/mL]) and ABI tertiles (severe [<0.40], moderate [0.40-<0.70], and mild [0.70-0.90]), with curve separation assessed using log-rank tests. Multivariable Cox proportional hazards modelling was used to evaluate the independent relationships of FABP3 and ABI with 2-year MALE after adjustment for baseline demographic and clinical covariates. To assess predictive performance for 2-year MALE, an extreme gradient boosting (XGBoost) classification model incorporating 10-fold cross-validation was trained using a combination of clinical covariates, plasma FABP3 levels, and ABI. Discriminatory performance was assessed using the area under the receiver operating characteristic curve (AUC). Results: The average participant age was 68 years (SD 12), and 34% (n = 340) were women. Mean ABI was 0.75 ± 0.25 and mean FABP3 concentration was 2.97 ± 2.06 ng/mL. Among the 644 participants with PAD, 558 (86.6%) had complete time-to-event data for MALE status, FABP3, and ABI. Over the median follow-up period of 2 years, 140 (25.1%) participants with PAD experienced MALE. Kaplan-Meier analyses demonstrated significant separation in MALE-free survival across FABP3 tertiles (log-rank p < 0.001). At 24 months, MALE-free survival was 100.0% in the FABP3 < 1.55 group, compared with 71.1% in the FABP3 1.55-3.55 group and 67.7% in the FABP3 > 3.55 group. In contrast, ABI severity groups showed less pronounced separation, with 24-month MALE-free survival rates of 80.3% for mild ABI, 73.2% for moderate ABI, and 71.3% for severe ABI, without a statistically significant overall difference (p = 0.170). In adjusted Cox proportional hazards models, FABP3 demonstrated strong prognostic performance for 2-year MALE. A 1 SD increase in log-transformed FABP3 was independently associated with a higher risk of 2-year MALE (HR 1.90, 95% CI 1.60-2.25; p < 0.001), with minimal change after additional adjustment for ABI (HR 1.90, 95% CI 1.60-2.24; p < 0.001). Machine learning analyses similarly favored FABP3 over ABI, with the FABP3-based model achieving an AUC of 0.773 compared to 0.686 for the ABI-based model. Adding ABI to the FABP3 model did not improve discrimination. Conclusions: Circulating plasma levels of FABP3 are strongly associated with PAD outcomes. Specifically, FABP3 demonstrated a stronger and more robust association with 2-year MALE compared to ABI. This study validates the prognostic value of FABP3 for PAD outcomes in comparison to ABI.

Ingestion of ethylene glycol-based antifreeze can lead to multi-organ dysfunction, most often presenting with reversible neurological impairment involving the basal ganglia or temporal lobes. Neurological symptoms and imaging abnormalities of patients typically resolve within several days. However, persistent symptoms associated with cerebral infarction in the parietal-occipital region are exceedingly rare. This article reports a case of cerebral infarction caused by poisoning due to massive ethylene glycol ingestion. The patient developed impaired consciousness and convulsions approximately six hours after ingesting a large quantity of ethylene glycol. The patient received antidotal therapy, hemodialysis, and supportive treatment, leading to recovery of consciousness and gradual improvement of renal function. Brain CT demonstrated low-density lesions in both cerebellar hemispheres and the left parietal-occipital lobe, consistent with cerebral infarction, with residual weakness of the right lower limb.

Thoracic outlet syndrome (TOS) refers to a group of conditions caused by extrinsic compression of neurovascular structures at the thoracic outlet. Arterial TOS (aTOS) is the rarest form and may present with upper limb ischemic symptoms such as pain, coldness, pallor, and numbness, most often due to bony abnormalities such as a cervical rib.  We report the case of a 19-year-old woman on combined oral contraceptive therapy who presented with acute ischemia of the right upper limb. Duplex ultrasound and computed tomography angiography revealed thrombosis of the right subclavian artery in the setting of a right cervical rib. The patient underwent urgent thrombectomy followed by definitive decompression through supraclavicular resection of the supernumerary rib.  This case illustrates a rare presentation of aTOS in a young patient and highlights the importance of prompt recognition and appropriate surgical management.

IntroductionWe present a case of acute limb ischemia (ALI) in a morbidly obese patient with prior femoro-popliteal artery PTFE bypass occlusion successfully treated with a hybrid femoral-to-posterior tibial artery bypass utilizing the previously occluded graft.Case ReportA 69-year-old morbidly obese woman presented with acute left leg pain and numbness with preserved motor function. Computed tomography angiography (CTA) demonstrates chronic superficial femoral artery and femoro-popliteal PTFE bypass occlusion with a new native popliteal artery thrombosis and loss of tibial runoffs. After systemic heparinization, the leg was revascularized through a small medial thigh incision and a jump PTFE bypass to the posterior tibial artery. The previously occluded femoro-popliteal artery bypass was accessed to re-establish proximal flow through a retrograde endovascular construction using a 7 mm by 25 cm Viabahn (Gore, Flagstaff, AZ) stent. This stent was used as a bridge with distal deployment within a new 6 mm PTFE graft, which was then anastomosed in an end to side fashion to a Linton patch of the posterior tibial artery. There were no postoperative complications, and the ankle-brachial-index was measured to be 0.98 with a CTA with runoffs confirming bypass patency.DiscussionALI in the setting of a prior bypass occlusion in a morbidly obese patient reflects the typical contemporary patient and disease complexity, which demands corrective revascularization with appropriate mitigation/prevention of other postoperative complications. A limited thigh exposure to access a previously occluded bypass can successfully restore in-line flow in these high-risk patients.ConclusionHybrid lower extremity revascularization is an alternative surgical modality to restore in-line flow to a lower extremity as a limb salvage option while avoiding groin re-exploration in a previously accessed groin for bypass construction in a morbidly obese patient.