A single-center retrospective analysis of 77 traumatic arterial injuries of lower extremities / 中华外科杂志

Objective: To analyze the treatment and clinical prognosis of lower extremity arterial injury caused by trauma. Methods: The clinical data of 77 patients with traumatic lower extremity arterial injury admitted to Department of Vascular Surgery,Yichang Central People's Hospital from January 2013 to June 2021 were collected retrospectively. There were 65 males and 12 females, with an average age of 47.4 years (range: 7 to 75 years). Among the 77 patients, 56 cases (72.7%) had open injury and 21 cases (27.3%) had closed injury. Iliac artery was injured in 9 cases (11.7%), common femoral artery in 7 cases (9.1%), superficial femoral artery in 1 case (1.3%), popliteal artery in 11 cases (14.3%) and inferior knee artery in 49 cases (63.6%). The treatment methods and clinical effects were analyzed. Results: One case with pelvic fracture combined the internal iliac artery injury and 1 case with multiple injuries involving the common femoral artery died of circulatory failure before surgery. Seventy-five cases received vascular-related operations, including arterial ligation in 24 cases, arterial reconstruction in 40 cases, stent graft implantation in 1 case, primary amputation in 2 cases, and arterial embolization in 8 cases. The overall mortality rate was 6.5% (5/77), all of which were closed injuries. Except for 2 cases who died before surgery, 3 cases with pelvic fracture combined the internal iliac artery injury died of multiple organ failure after internal iliac artery embolization. There were 8 cases received amputation (10.4%, 8/77), 5 cases with closed injury and 3 cases with open injury. In addition to 2 cases with primary amputation, 6 cases underwent secondary amputation due to ischemia-reperfusion injury after revascularization (4 cases with popliteal artery injury and 2 cases with subpatellar artery injury). The average followed-up time was 17 months (range: 2 months to 8 years). One patient with femoral artery injury underwent autologous great saphenous vein bypass, and lower limb artery CT angiography was re-examined 6 months after the operation, and 30% distal anastomotic stenosis was found. Ankle brachial index<0.8 was found in two patients 1 year after popliteal artery repair, but none of the patients had intermittent claudication symptoms, and no further intervention was performed. Five patients suffered delayed healing due to severe lower limb injury, fracture and skin injury. Among them, 2 cases had poor wound healing at the stump of amputation, which gradually healed 3 to 5 months after several debridements. The other 3 vascular injury combined with tibial fracture patients had delayed tibial healing after surgery, but no symptoms of vascular ischemia occurred. All the other patients recovered well and no other serious complications occurred. Conclusions: The proportion of death and disability in patients with lower limb artery injury caused by trauma is high. Active and orderly surgical repair according to the site and type of injury can reduce the mortality, save the function of the affected limb, and promote the healing of injury.

Mid- and long-term outcomes and prognostic factors of drug-coated balloon angioplasty for treatment of femoropopliteal long lesions / 中华外科杂志

Objective: To examine the effective and safe outcomes of drug-coated balloon (DCB) angioplasty for the treatment of femoropopliteal long lesions in mid-term and long-term follow-up. Methods: The clinical data of 114 patients with symptomatic (Rutherford 2 to 6) femoropopliteal long lesions who underwent angioplasty with DCB between June 2016 and May 2021 at Department of Vascular Surgery,Beijing Tsinghua Changgung Hospital were retrospectively analyzed. A total of 75 males and 39 females were enrolled, aged (71.9±8.4)years (range: 49 to 89 years). Among 138 lesions in 114 patients, there were 111 de nove lesions (80.4%, 111/138). Total occlusions were recanalized in 116 limbs (84.1%, 116/138). The lesion length was (280.9±78.7)mm (range: 150 to 520 mm). DCB angioplasty combined with debulking devices was used in 59 lesions (42.8%, 59/138).The bail-out stent implantation was performed in 27 limbs (19.6%, 27/138). The Kaplan-Meier method was used to evaluate cumulative primary patency rate, freedom from the clinically driven target lesion revascularization (CD-TLR) rate and accumulate survival rate. Univariate and multivariate analyses with Cox proportional hazards models were performed to determine the significant prognostic factors for primary patency. Results: DCB angioplasty was completed in 114 patients. The technical success rate was 98.2%(112/114). The mean follow-up time was 18 months (range: 3 to 54 months).The results showed that primary patency rates at 12, 24 and 36 months postoperatively were 87.5%, 75.2% and 55.1%, respectively. Freedom from CD-TLR rate at 12, 24 and 36 months postoperatively were 92.4%, 81.8% and 68.7%, respectively. Accumulate survival rate at 12, 24 and 36 months postoperatively were 96.2%, 94.0% and 80.2%. Multivariate Cox's regression analyses showed that chronic limb-threatening ischemia(CLTI) (HR=2.629, 95%CI:1.519 to 4.547, P<0.01) and hyperlipidemia (HR=2.228, 95%CI: 1.004 to 4.948, P=0.026) were independent prognosis factors for primary patency in DCB treatment of femoropopliteal long lesions. Conclusions: DCB provided favorable outcomes for the treatment of femoropopliteal long lesions. CLTI and hyperlipidemia are independent prognosis factors for restenosis after DCB angioplasty.

Comparison of standard balloon and drug-coated balloon angioplasty in patients with the below-the-knee peripheral artery disease

SUMMARY OBJECTIVE: The objective of this study was to compare the interventions of percutaneous transluminal drug-coated balloon angioplasty (DCB PTA) and standard PTA in the treatment of patients with the below-the-knee peripheral artery disease (BTK PAD). METHODS: Overall, 196 patients (113 males and 83 females; mean age: 63.56±11.94 years; 45-83 years) were treated with PTA for BTK PAD between June 2014 and March 2019. RESULT: Standard PTA (group 1; 96 patients) and DCB PTA (group 2; 100 patients) results were analyzed and compared retrospectively. No statistically significant difference was found between the mean ages of group 1 and 2 patients (p=0.371, p>0.05). Demographic and clinical data were compared and no any statistically significant differences was found between the two groups. Comparing in terms of the iliac lesion, there was no statistically significant difference between the two groups. However, a statistically significant difference was found between the two groups in terms of frequency of popliteal lesions (p=0.001; p<0.05). There was not a statistically significant difference between the two groups in terms of other lesions. In addition, limb salvage rates were 82.0% (18 amputations) and 65.6% (33 amputations) in the drug-release balloon group and the naked balloon group, at the end of 1 year, respectively. No distal embolism, limb-threatening ischemia, and mortality were observed in any patients. CONCLUSIONS: Based on this study, patients in the DCB group had significantly higher rates of primary patency as compared with the other patients.

Isquemia crítica de miembros inferiores en paciente joven: presentación atípica del síndrome de atrapamiento poplíteo / Critical lower extremity ischemia in a young patient: atypical presentation of the popliteal artery entrapment syndrome

Introducción. El síndrome de atrapamiento poplíteo es una entidad infrecuente, cuya incidencia oscila entre 0,17 y 3,5 %, representando una de las principales causas de isquemia en miembros inferiores en adultos jóvenes. Suele manifestarse con claudicación intermitente (69 %) o isquemia aguda (26 %), siendo muy rara su presentación con isquemia crítica de miembros inferiores. Caso clínico. Paciente de 30 años quien presentó úlcera subungueal en primer dedo de pie derecho con dolor intenso. En la exploración física no se palpaban pulsos distales y se observó palidez cutánea intensa y frialdad. Se realizó arteriografía donde se observó defecto de repleción de bordes regulares y desplazamiento medial de la arteria poplítea. La resonancia magnética mostró una inserción anómala del gastrocnemio medial, con lo que se hizo diagnóstico de síndrome de atrapamiento poplíteo tipo I. Mediante abordaje posterior se realizó reconstrucción vascular con injerto venoso y sección tendinosa del gastrocnemio medial. En el postoperatorio inmediato el paciente recupera pulso pedio y en el seguimiento a un año el paciente no presenta clínica de isquemia de miembros inferiores, encontrándose el baipás permeable. Discusión. A pesar de su baja incidencia, es importante incluir el síndrome de atrapamiento poplíteo en el diagnóstico diferencial de isquemia en miembros inferiores en adultos jóvenes. Su presentación con isquemia crítica es excepcional, encontrando muy pocos casos publicados en la literatura. La reconstrucción arterial precoz mediante injerto o plastia con material autólogo constituye el tratamiento de elección

Introduction. The popliteal entrapment syndrome is an infrequent entity, whose incidence ranges between 0.17 and 3.5%, representing one of the main causes of lower limb ischemia in young adults. It usually manifests with intermittent claudication (69%) or acute ischemia (26%), being very rare its presentation with critical ischemia of the lower limbs.Clinical case. A 30-year-old patient with a history of smoking, with no other risk factors, who presented with a subungual ulcer on the first right toe. On physical examination, distal pulses are not palpated, intense skin paleness and coldness are observed. Magnetic resonance imaging showed an anomalous insertion of the medial gastrocnemius with extrinsic compression of the popliteal artery, confirming a diagnosis of popliteal entrapment syndrome type I. Vascular reconstruction with venous graft and tendon section of the medial gastrocnemius was performed through a posterior approach. In the immediate postoperative period, the patient recovers a pediatric pulse and in the one-year follow-up the patient does not present symptoms of lower limb ischemia, finding the bypass patent. Discussion. Despite its low incidence, it is important to include popliteal impingement syndrome in the differential diagnosis of lower limb ischemia in young adults. Its presentation with critical ischemia is exceptional, finding very few cases published in the literature. Early arterial reconstruction by graft or plasty with autologous material is the treatment of choice

Endovascular revascularization of chronic total arterial occlusion of the lower limb using the SAFARI technique / Revascularização endovascular utilizando a técnica SAFARI em casos de oclusão arterial total do membro inferior

Abstract The SAFARI technique or Subintimal Arterial Flossing with Antegrade-Retrograde Intervention is an endovascular procedure that allows recanalization of Chronic Total Occlusive (CTO) lesions when conventional subintimal angioplasty is unsuccessful. Retrograde access is usually obtained through the popliteal, anterior tibial, dorsalis pedis artery, or posterior tibial arteries and may potentially provide more options for endovascular interventions in limb salvage. The case of an 81-year-old man with a history of uncontrolled hypertension, diabetes mellitus, and dyslipidemia is presented. He presented with a cutaneous ulcer on the right lower limb with torpid evolution and poor healing. The Doppler ultrasound and arteriographic study revealed a CTO lesion of the popliteal artery that was not a candidate for antegrade endovascular revascularization, but was successfully treated using the SAFARI technique. The patient had no perioperative complications, the wound showed better healing, and he was discharged with an indication of daily dressings and control by an external outpatient clinic.

Resumo A técnica SAFARI, ou Subintimal Arterial Flossing with Antegrade-Retrograde Intervention, é um procedimento endovascular que permite a recanalização de lesões por oclusão total crônica (OTC) em caso de fracasso da angioplastia subintimal convencional. O acesso retrógrado é geralmente obtido através da artéria poplítea, tibial anterior, pediosa ou tibial posterior e pode fornecer mais alternativas de intervenções endovasculares para o salvamento do membro. É apresentado o caso de um homem de 81 anos com histórico de hipertenção não controlada, diabetes melito e dislipidemia. Ele apresentava uma lesão ulcerativa cutânea no membro inferior direito com evolução tórpida e má cicatrização. O ultrassom Doppler e o estudo arteriográfico revelaram uma lesão por OTC na artéria poplítea. O paciente não era candidato a revascularização endovascular anterógrada; sendo assim, esta foi realizada com successo utilizando a técnica SAFARI. O paciente não apresentou complicações perioperatórias e recebeu alta com indicação de cuidados diários com a ferida e controle em um ambulatório externo. Além disso, a ferida apresentou melhor cicatrização.

Unusual presentation of moyamoya disease with popliteal involvement: case report and review of the literature / Apresentação incomum de doença de moyamoya com envolvimento poplíteo: relato de caso e revisão da literatura

Abstract Moyamoya disease is a rare disorder that involves the cerebrovascular system. Usually, it leads to occlusion of the arteries of the cerebral system and causes cerebral circulatory complaints. A 48-year-old female patient was admitted to our clinic with intermittent claudication in both legs. Biphasic and monophasic waveform patterns were detected bilaterally in distal (trifurcation arteries) lower extremities with Doppler sonography. The patient therefore underwent systemic vascular examination. Computed tomography angiography revealed bilateral carotid occlusion at the level of supraclinoid segments, and opacifications were detected at the distal segments of the bilateral anterior cerebellar and middle cerebellar arteries. The patient was diagnosed with moyamoya disease, and anticoagulant treatment was started. In conclusion, most previous reports have presented the cerebrovascular involvement of moyamoya disease. However, this disease can involve different peripheral vascular systems and careful and systemic vascular examination is necessary for an exact diagnosis.

Resumo A doença de moyamoya é um distúrbio raro que envolve o sistema cerebrovascular. Normalmente, leva à oclusão das artérias do sistema cerebral e causa problemas circulatórios no cérebro. Uma mulher de 48 anos foi admitida em nossa clínica com claudicação intermitente em ambas as pernas. Na ultrassonografia com Doppler, foram detectados padrões de formato de onda bifásico e monofásico nas extremidades inferiores distais (artérias da trifurcação) de forma bilateral. Portanto, realizou-se o exame vascular sistêmico na paciente. A angiografia por tomografia computadorizada revelou oclusão carotídea bilateral no nível dos segmentos supraclinoides, e opacificações foram detectadas nos segmentos distais das artérias cerebelares anteriores e médias de forma bilateral. A paciente foi diagnosticada com doença de moyamoya, e o tratamento anticoagulante foi iniciado. Em conclusão, a maioria dos relatos anteriores apresentou o envolvimento cerebrovascular da doença de moyamoya. No entanto, essa doença pode envolver diferentes sistemas vasculares periféricos, e um exame vascular sistêmico minucioso é necessário para um diagnóstico exato.

Trombosis venosa profunda secundaria a aneurisma de la arteria poplítea: caso clínico-radiológico y revisión de la literatura / Deep vein thrombosis secondary to popliteal artery aneurysm: literature review and presentation of case

Popliteal artery aneurysms is the most frequent peripheral aneurysm, predominantly affects men over 60 years of age and has a high morbidity associated to his complications, among which are ischemic complication, which can often end in amputation of the limb. Less frequent complications such as neuropathic and venous complications, particularly deep vein thrombosis, are equally relevant. Case presentation: Patient with an aneurysm of the popliteal artery complicated by thrombosis of the adjacent popliteal vein. Color Doppler ultrasound plays a fundamental role in the diagnosis.

Angioplastia transluminal percutánea de femoral superficial en paciente con oclusión de sectores fémoro-poplíteo e infra-poplíteo / Percutaneous Transluminal Angioplasty of the Superficial Femoral Artery in a Patient with Occlusion in the femoro-popliteal and infra-popliteal Sector

Introducción: La indicación más clara de revascularización en las extremidades inferiores lo constituye la presencia de lesiones isquémicas y el tratamiento de elección, siempre que sea posible, es el endovascular debido a su buena permeabilidad, baja morbilidad y mortalidad. Objetivo: Presentar un caso en el que se utilizó la angioplastia transluminal percutánea del sector fémoro-poplíteo. Presentación del caso: Se presenta un caso con diagnóstico de enfermedad arterial periférica en la extremidad inferior derecha. La angioplastia transluminal percutánea se utilizó para cicatrizar lesiones isquémicas aún en presencia de oclusiones no revascularizables de las arterias infra-poplíteas. El paciente presentaba al examen físico lesión isquémica en el primer dedo y patrón esteno-oclusivo fémoro-poplíteo. Se detectó disminución de los índices de presiones en poplítea y distales. En la arteriografía se apreciaron lesiones esteno-oclusivas en la femoral superficial y oclusión de las arterias infra-poplíteas. Se realizó angioplastia transluminal percutánea de la femoral superficial y el paciente recuperó pulso poplíteo con mejoría hemodinámica. Evolucionó satisfactoriamente y egresó con tratamiento médico. A los cinco meses de operado mantiene su pulso poplíteo presente y la lesión cicatrizada. Conclusión: La angioplastia del sector fémoro-poplíteo es beneficiosa para la cicatrización de la lesión isquémica aún en presencia de oclusiones infra-poplíteas no revascularizables(AU)

Introduction: The clearest indication for revascularization in lower limbs is the presence of ischemic lesions. The treatment of choice, whenever possible, is the endovascular one, due to its good permeability, as well as low morbidity and mortality. Objective: To present a case in which percutaneous transluminal angioplasty of the femoro-popliteal sector. Case presentation: A case is presented with a diagnosis of peripheral arterial disease in the right lower limb. The percutaneous transluminal angioplastywas used to heal ischemic lesions even in the presence of nonrevascularizable occlusions of the infra-popliteal arteries. On physical examination, the patient presented an ischemic lesion on the first finger and a femoro-popliteal steno-occlusive pattern. Decrease in pressure indices was detected in the popliteal and the distal ones. Arteriography showed steno-occlusive lesions in the superficial femoral and occlusion of the infra-popliteal arteries. Percutaneous transluminal angioplasty of the superficial femoral artery was performed and the patient recovered the popliteal pulse with hemodynamic improvement. The patient evolved satisfactorily and was discharged with medical treatment. Five months after surgery, the patient maintains popliteal pulse and the lesion has cicatrized. Conclusion: Angioplasty of the femoro-popliteal sector prove beneficial for the healing of the ischemic lesion even in the presence of nonrevascularizable infra-popliteal occlusions(AU)

Acute effects of strength exercise with blood flow restriction on the arterial resistance index / Efeitos agudos do exercício de força com restrição do fluxo sanguíneo sobre o índice de resistência arterial

ABSTRACT The present study aimed to evaluate the acute behavior of the brachial artery resistance index (BARI) and popliteal artery resistance index (PARI) in response to low intensity strength exercises involving small (SMG) and large muscle groups (LMG) performed with and without blood flow restriction. Eleven men (age 23 ± 3.29 years) underwent a four-arm, randomized, cross-over experiment: Small muscle group exercise (SMG), small muscle groups with blood flow restriction (SMG+BFR), large muscle groups (LMG) and large muscle groups with blood flow restriction (LMG+BFR). The behavior of BARI and PARI was evaluated at rest, immediately after exercise, and at 15 and 30 minutes during recovery. Data analysis showed a significant reduction of the BARI from rest to post-exercise only in the protocols involving SMG, regardless of the BFR (p <0.05). Protocols involving LMG, with or without BFR, did not affect PARI (p> 0.05), but were efficient to promote significant increases in BARI (p <0.05) immediately after exercise. Our findings indicate that the exercises involving SMG, regardless of BFR, are efficient to promote local vasodilatation (brachial artery), but without systemic effects. None of the analyzed protocols affected the PARI behavior.

RESUMO O presente estudo objetivou avaliar o comportamento agudo do índice de resistência da artéria braquial (IRAB) e da artéria poplítea (IRAP) em resposta a exercícios de força de baixa intensidade envolvendo pequenos (PGM) e grandes grupos musculares (GGM), realizado com e sem restrição de fluxo sanguíneo. Onze homens (idade 23 ± 3,29 anos) realizaram um experimento randomizado, cruzado, com quatro braços: Exercício para pequenos grupos musculares (PGM), pequenos grupos musculares com restrição de fluxo sanguíneo (PGM+RFS), grandes grupos musculares (GGM) e grandes grupos musculares com restrição de fluxo sanguíneo (GGM+RFS). O comportamento de IRAB e IRAP foi avaliado em repouso, mediatamente após o exercício, e aos 15 e 30 minutos da recuperação. A análise dos dados mostrou uma redução significativa do IRAB do repouso para o pós-exercício apenas nos protocolos de PGM com ou sem RFS (p <0,05). Protocolos envolvendo GGM, independentemente do BFR, não afetaram o IRAP (p> 0,05), porém, foram eficientes para promover aumentos significativos do IRAB (p <0,05) imediatamente após o exercício. Nossos achados indicam que os exercícios envolvendo PGM, independentemente da BFR, são capazes de promover a vasodilatação local (artéria braquial), porém, sem efeitos sistêmicos. Nenhum dos protocolos analisados afetou o comportamento do IRAP.

Síndrome do aprisionamento da artéria tibial anterior bilateral pelo retináculo extensor do tornozelo: relato de caso / Bilateral anterior tibial artery entrapment by the ankle extensor retinaculum: case report

Resumo Os aprisionamentos vasculares são raros. Nos membros inferiores, geralmente são assintomáticos, mas podem causar claudicação intermitente atípica em indivíduos jovens sem fatores de risco para aterosclerose ou doenças inflamatórias. O vaso mais frequentemente acometido é a artéria poplítea, causando a síndrome do aprisionamento da artéria poplítea (SAAP), com sintomas na região dos músculos infrapatelares. Quando o desconforto ao esforço é mais distal, deve-se pensar em outros locais de aprisionamento arterial, como a artéria tibial anterior. Neste trabalho, é relatado o caso de um paciente com claudicação intermitente nos pés devido ao aprisionamento da artéria tibial anterior (AATA) bilateral, causado pelo retináculo dos músculos extensores e diagnosticado pela ultrassonografia vascular e angiotomografia durante flexão plantar. O paciente foi tratado cirurgicamente, evoluindo com melhora dos sintomas clínicos.

Abstract Vascular entrapment is rare. In the lower limbs it is generally asymptomatic, but may cause atypical intermittent claudication in young people without risk factors for atherosclerosis and inflammatory diseases. The most common type of compression involves the popliteal artery, causing symptoms in the region of the infra-patellar muscles. When discomfort is more distal, other entrapment points should be considered, such as the anterior tibial artery. This article reports the case of a patient with intermittent claudication in both feet due to extrinsic compression of the anterior tibial artery bilaterally by the extensor retinaculum of the ankle, diagnosed by vascular ultrasonography and angiotomography during plantar flexion maneuvers. The patient was treated surgically, resulting in improvement of clinical symptoms.

Rotura de aneurisma de artéria poplítea em paciente clinicamente diagnosticado com síndrome de Marfan / Ruptured popliteal artery aneurysm in a patient with a clinical diagnosis of Marfan syndrome

Resumo A artéria poplítea é o principal local para a ocorrência de aneurismas periféricos. Suas formas de apresentação agudas são potencialmente ameaçadoras à viabilidade do membro e à vida, dentre as quais destacamos a sua rotura. Apesar de ser um evento raro, sua rotura demanda rápida proposta de intervenção para satisfatório desfecho terapêutico. O tratamento padrão-ouro é o cirúrgico convencional e se dá pela interposição de veia safena magna. Trabalhos feitos nas últimas décadas vêm encontrando associações entre a síndrome de Marfan e aneurismas periféricos. Este relato apresenta um caso de um aneurisma de artéria poplítea esquerda roto tratado com sucesso em um paciente de 82 anos diagnosticado clinicamente como portador de síndrome de Marfan previamente desconhecida.

Abstract The popliteal artery is the main site of occurrence of peripheral aneurysms. Acute presentations constitute a potential threat to limb viability and to life, especially in the event of rupture. Rupture is a rare event, but one that demands an immediate intervention decision to achieve a satisfactory treatment outcome. The gold standard treatment is conventional surgery, effecting repair by interposition of a great saphenous vein graft. Studies conducted in recent decades have found associations between Marfan Syndrome and peripheral aneurysms. This report presents a case of a ruptured left popliteal artery aneurysm successfully treated in an 82-year-old patient clinically diagnosed with previously unknown Marfan syndrome.

Stents in the femoropopliteal territory: prevalence of fractures and their consequences / Stents no território fêmoro-poplíteo: prevalência de fraturas e suas consequências

ABSTRACT Endovascular treatment for femoropopliteal arterial disease has made revascularization procedures less invasive, but the self-expanding stents used can suffer great wear in arteries with extreme mobility. Objective: to evaluate the prevalence of fractures in stents implanted in the femoropopliteal segment, to identify predisposing factors and consequences on arterial patency. Method: between March and June 2019, thirty patients previously operated for femoropopliteal obstruction underwent stent X-rays in anteroposterior and lateral views to detect fractures and Doppler to analyze arterial patency. Results: we observed 12 cases with fractures (33.3%): 1 type I (2.8%), 3 type II (8.3%), 5 type III (13.9%), 3 type IV (8.3%) and no type V. According to the TASC II we had 1 in group B (8.3%), 6 in group C (50%) and 5 in group D (41.6%) p <0.004. The number of stents per limb was 3.1 (± 1.3) in cases of fracture versus 2.3 (± 1.3) in cases without fracture (p = 0.08). The extension was 274.17mm (± 100.94) in cases of fracture and 230.83mm (± 135.44) in cases without fracture (p = 0.29). On Doppler we had: 17 patients (47.2%) without stenosis, 9 patients (25%) with stenosis> 50% and 10 patients (27.8%) with occlusion (p = 0.37). There was no correlation between fracture and arterial obstruction (p = 0.33). Conclusion: stent fractures are a frequent finding in the femoropopliteal area (33.3%), being more prevalent in cases of more advanced disease (C and D). There was no association between the finding of fracture and arterial obstruction.

RESUMO Os tratamentos endovasculares para a doença arterial obstrutiva fêmoro-poplítea tornaram os procedimentos de revascularização menos invasivos, porém os stents metálicos autoexpansíveis utilizados podem sofrer grande desgaste em artérias com extrema mobilidade. Objetivo: avaliar a prevalência de fraturas em stents implantados no segmento fêmoro-poplíteo, identificar fatores predisponentes e possíveis consequências sobre a patência arterial. Métodos: entre março a junho de 2019, trinta pacientes previamente operados por obstrução fêmoro-poplítea realizaram RX dos stents em incidências ântero-posterior e perfil para detectar fraturas e eco Doppler para analisar a patência arterial. Resultados: observamos 12 casos com fraturas (33,3%): 1 do tipo I (2,8%), 3 do tipo II (8,3%), 5 do tipo III (13,9%), 3 do tipo IV (8,3%) e nenhuma tipo V. Segundo a classificação TASC II, tivemos 1 no grupo B (8,3%), 6 no grupo C (50%) e 5 no grupo D (41,6%) p<0,004. O número de stents por membro foi de 3,1 (±1,3) nos casos de fratura contra 2,3 (±1,3) nos casos sem fratura (p = 0,08). A extensão tratada foi 274,17mm (±100,94) nos casos de fratura e 230,83mm (±135,44) nos casos sem fratura (p=0,29). No Doppler tivemos: 17 pacientes (47,2%) sem estenose, 9 pacientes (25%) com estenose>50% e 10 pacientes (27,8%) com oclusão (p=0,37). Não houve correlação entre fratura e obstrução arterial (p=0,33). Conclusão: as fraturas de stents são um achado frequente no setor fêmoro-poplíteo (33,3%) sendo mais prevalentes nos casos de doença mais avançada TASC II C e D. Não houve associação entre o achado de fratura e obstrução arterial.

Enfermedad quística adventicial de la arteria poplítea: presentación imagenológica de una causa rara de claudicación intermitente / Adventitial cystic disease of the popliteal artery as a cause of intermittent claudication: not your usual suspect: report of one case

Adventitial cystic disease of the popliteal artery is a rare condition of uncertain etiology, which presents as intermittent claudication of the lower extremity in middle-age patients. We report a 44-year-old man presenting with intermittent claudication of his left leg. MR angiography showed cystic parietal lesions that caused compression with partial occlusion of the left popliteal artery. Surgical resection of the affected segment was performed, with venous graft interposition. The histopathological analysis of the surgical specimen was consistent with cystic adventitial disease.

Optimal location of local anesthetic injection in the interspace between the popliteal artery and posterior capsule of the knee (iPACK) for posterior knee pain after total knee arthroplasty: an anatomical and clinical study / 대한마취과학회지

BACKGROUND: This study aimed to determine the optimal location of local anesthetic injection in the interspace between the popliteal artery and posterior capsule of the knee (iPACK), using the anatomical pattern of the articular branch of tibial nerve (ABTN). We hypothesized that injection at the level of ABTN forming a popliteal plexus would mainly spread throughout the popliteal fossa without contacting the tibial or peroneal nerves. METHODS: The anatomical study included 30 soft cadavers. Ultrasound-guided dye injection was performed in legs of 10 cadavers after identifying the position of the ABTN and surrounding structures, followed by dissection to assess its spread. Clinical study was conducted in 15 patients undergoing total knee arthroplasty (TKA) with ultrasound-guided injection in the iPACK. All patients also received continuous adductor canal block. Sensorimotor function of the tibial and common peroneal nerves was determined. RESULTS: In the distal portion of the popliteal fossa, the tibial nerve and popliteal vessels ran superficially and closely together. The trajectory of ABTN ran lateral to the popliteal vasculature, forming a plexus towards the posterior capsule of the knee below the medial side of the upper edge of lateral femoral condyle. In cadavers, the ABTN and surrounding area of the popliteal plexus were stained with dye after injection. In the clinical study, no patients experienced complete motor or sensory blocks. CONCLUSIONS: We described a modified iPACK technique injection at the level of the ABTN forming the popliteal plexus, and it may constitute an optional anesthetic regimen to promote early ambulation following TKA.

Implementation of the IPACK (Infiltration between the Popliteal Artery and Capsule of the Knee) block into a multimodal analgesic pathway for total knee replacement / 대한마취과학회지

BACKGROUND: The Infiltration between the Popliteal Artery and Capsule of the Knee (IPACK) block is a new anesthesiologist- administered analgesic technique for controlling posterior knee pain that has not yet been well studied in total knee arthroplasty (TKA) patients. We compared pain outcomes in TKA patients before and after implementation of the IPACK with the hypothesis that patients receiving IPACK blocks will report lower pain scores on postoperative day (POD) 0 than non-IPACK patients. METHODS: With Institutional Review Board approval, we retrospectively reviewed data for consecutive TKA patients by a single surgeon 4 months before (PRE) and after (POST) IPACK implementation. All TKA patients received adductor canal catheters and peri-operative multimodal analgesia. The primary outcome was pain on POD 0. Other outcomes were daily pain scores, opioid consumption, ambulation distance, length of stay, and adverse events within 30 days. RESULTS: Post-implementation, 48/50 (96%) of TKA patients received an IPACK block, and they were compared with 32 patients in the PRE group. On POD 0, the lowest pain score (median [10th–90th percentiles]) was significantly lower for the POST group compared to the PRE group (0 [0–4.3] vs. 2.5 [0–7]; P = 0.003). The highest patient-reported pain scores on any POD were similar between groups with no differences in other outcomes. CONCLUSIONS: Within a multimodal analgesic protocol, addition of IPACK blocks decreased the lowest pain scores on POD 0. Although other outcomes were unchanged, there may be a role for new opioid-sparing analgesic techniques, and changing clinical practice change can occur rapidly.

Thrombosis of a Long-Segment Aneurysm from the Iliac to Popliteal Artery Associated with Arteriovenous Malformation and Varicose Veins

A 58-year-old male patient with severe claudication due to thrombosis of the left ilio-femoro-popliteal artery aneurysm. He also had a venous stasis ulcer with a history of multiple embolotherapy of arteriovenous malformation. Duplex sonography revealed reflux and varicose veins of the left great saphenous vein (GSV). A sequential bypass surgery was performed that consisted of excision of the left external iliac and common femoral artery aneurysm, external iliac to deep femoral interposition with an expanded polytetrafluoroethylene graft, and femoro-posterior tibial artery bypass with the reversed left GSV. Symptoms of claudication were alleviated and the chronic ulcer was healed in time. To our knowledge, this is the first report of successful bypass in a patient with arterial aneurysm, arteriovenous malformation, and venous insufficiency that can be diagnosed as an atypical case of Parkes Weber syndrome. Long-term follow-up is needed to define the fate of aneurysms and varicose vein graft.

Risk Factors of Amputation in Lower Extremity Trauma with Combined Femoropopliteal Arterial Injury

PURPOSE: The clinical characteristics and results of femoropopliteal artery injury (FPAI) remain unclear. In this study, we evaluated the outcomes and risk factors of limb loss in patients treated for FPAI. MATERIALS AND METHODS: We retrospectively reviewed data from a database of patients who underwent revascularization for an FPAI at a single institution between January 2013 and December 2017. We reviewed and analyzed the characteristics, postoperative results, and factors that influence amputation rates. RESULTS: Twenty-four femoropopliteal arterial reconstructions in 24 patients were included in this study. Among the patients were 20 (83.3%) male with a first-quartile age of 28 years and a third-quartile age of 45 years (range, 15–68 years). The mean injury severity score (ISS) was 16 (range, 4–55), and 5 patients (20.8%) had ISSs of >20 points. The mean mangled extremity severity score (MESS) was 3.8 (range, 1–11), and 8 patients (33.3%) had MESSs of >5 points. In terms of arterial reconstruction methods, autogenous saphenous vein grafting, vein patching, and primary closure were performed in 9 patients (37.5%), 4 patients (16.7%), and 11 patients (45.8%), respectively. Despite arterial reconstruction, 5 patients (20.8%) underwent above-knee amputation. ISSs of >20, MESSs of >7, and orthopedic fixation were statistically significant factors associated with amputation. CONCLUSION: In cases of FPAI with ISSs of >20, MESSs of >7, and orthopedic fixation, amputations should be considered. We were also careful to attempt limb salvage in such cases.

Giant Popliteal Artery Aneurysm in a Teenager: An Unusual Occurrence / 대한흉부외과학회지

Giant popliteal artery aneurysm is an uncommon entity. If untreated, it results in life-threatening complications. It is usually seen in older patients (over 60 years of age), and atherosclerotic disease is its main cause. Few cases have been reported in young adults, and its incidence in teenagers is exceptionally rare, with scarce case reports in the literature. We report a case of left popliteal artery aneurysm in a 16-year-old and its successful surgical treatment through resection and repair with a synthetic interposition graft.

Tratamento da doença arterial obstrutiva periférica em território femoropoplíteo com stent primário: análise em até 24 meses / Primary stenting for femoropopliteal peripheral arterial disease: analysis up to 24 months

O stent primário é uma opção de tratamento bem estabelecida para a doença arterial periférica em território femoropoplíteo. Estudos nacionais são escassos. Objetivos Avaliar desfechos clínicos e radiológicos em curto e médio prazo em pacientes classificados como Rutherford 3-6, tratados com o uso de stent em lesões femoropoplíteas. Métodos A análise foi realizada com base em um banco de dados prospectivamente mantido de doentes tratados entre julho de 2012 e julho de 2015. O objetivo primário foi a perviedade. Os objetivos secundários foram melhora na classificação de Rutherford, índice tornozelo/braço, revascularização do vaso-alvo, taxa de salvamento do membro e óbito em até 24 meses. Resultados Foram incluídos 64 pacientes, sendo 61 com lesões TASC II A/B (95%). A taxa de perviedade primária em 6, 12 e 24 meses foi de 95,2%, 79,1% e 57,9%, respectivamente. A análise de regressão de Cox revelou uma menor perviedade em pacientes com doença oclusiva (RR, 6,64, IC 95%, 1,52-28,99, p = 0,02), bem como uma perda de perviedade cerca de seis vezes maior em doentes TASC B do que TASC A (RR, 5,95, IC 95%, 1,67-21,3, p = 0,0061). Em 12 meses, 90,38% dos doentes permaneceram assintomáticos. A taxa de salvamento do membro em 24 meses foi de 94,3% (IC 95%, 87,9-100%). A ausência de revascularização do vaso-alvo em 24 meses foi de 90,5% (IC 95%, 82,8-98,9%). Conclusões Os resultados foram compatíveis com estudos internacionais, apesar do estágio mais avançado da doença vascular observada em nosso grupo. Piores desfechos foram associados a doença oclusiva e lesões complexas

Primary stenting is a well-established treatment option for femoropopliteal arterial obstructive disease. There is a shortage of Brazilian studies of the subject. Objectives To evaluate short and mid-term clinical and radiological outcomes in patients classified as Rutherford 3-6 and treated with stenting of femoropopliteal lesions. Methods Analysis based on a prospectively populated database of patients treated from July 2012 to July 2015. The primary endpoint was primary patency. Secondary endpoints were clinical and ankle/brachial index changes. Target Vessel Revascularization, limb salvage rate and death, within a 24-month follow-up period. Results 64 patients were enrolled, including 61 TASC II A / B lesions (95%). The primary patency rates at 6, 12, and 24 months were 95.2%, 79.1% and 57.9%, respectively. Cox regression analysis revealed lower patency rates in patients with occlusive disease (hazard ratio [HR], 6.64; 95% confidence interval [CI], 1.52-28,99, p = 0.02), as well as patency loss about 6 times higher in TASC B than in TASC A patients ([HR], 5.95, 95% CI, 1.67-21.3, p = 0.0061). At 12 months, 90.38% of the patients remained asymptomatic. The limb salvage rate at 24 months was 94.3% (95% CI, 87.9-100%). Freedom from TVR at 24 months was 90.5% (95% CI 82.8-98.9%). Conclusions Results of primary patency were compatible with international studies, despite the more advanced stage of the vascular disease observed in our group. Occlusive disease and complex lesions were both associated with worse outcomes

Angioplastia de salvamento de extremidad con isquemia crítica infrapoplítea / Percutaneous Transluminal Angioplasty of Critical Limb Ischemia

Objetivo: Evaluar y describir los resultados clínicos de la técnica Angioplastia de rescate en pacientes con isquemia crítica de miembros inferiores con enfermedad arterial infrapoplítea en un centro de atención nivel IV. Materiales y métodos: Estudio de cohorte ambispectivo analítico observacional. Resultados: Se realizaron angioplastias infrapoplíteas en el Servicio de Radiología de FOSCAL y FOSCAL Internacional entre septiembre de 2013 y abril de 2016, a 65 pacientes. Previo al procedimiento, en el 89 % de los pacientes se observó claudicación y dolor; en el 88 %, frialdad de la extremidad; en el 81 %, úlcera y en el 64 %, infección. En el 63 % de la población se encontraron tres síntomas asociados. Se dividieron los pacientes en dos grupos: el primero, aquellos a quienes se les había realizado angioplastia en un solo vaso y el segundo, a quienes se les había realizado angioplastia en dos o más vasos. Se encontró que el tiempo libre de amputación fue mayor en el grupo uno, comparado con el dos, con valor de P estadísticamente significativo. Conclusión: La angioplastia de vasos infrapoplíteos en pacientes con enfermedad arterial periférica (EAP) e isquemia crítica de miembros inferiores disminuye el dolor, la claudicación y la infección en los pacientes. Favorece una tasa baja de amputaciones mayores posteriores a la terapia como medida de salvamento de la extremidad. La probabilidad de supervivencia de la extremidad a los 573 días es del 50 %.

Objective: To evaluate and describe the clinical results of percutaneous transluminal angioplasty of critical limb ischemia in a level IV care center. Materials and methods: Observational analytical ambispective cohort study. Results: An infra-popliteal angioplasty was performed in the Radiology service of FOSCAL and FOSCAL International between the months of September 2013 and April 2016 to 65 patients. Prior to the procedure, 89% of the patients presented claudication and pain, 88% coldness of the limb, 81% of the patients presented ulceration and 64% infection, noting that 63% of the population had 3 associated symptoms. The patients were divided into two groups; the first, those who had undergone angioplasty in a single vessel and the second group who had undergone angioplasty in two or more vessels. We found that the amputation-free time was greater in the group one compared to group two, with a statistically significant P value. Conclusion: Angioplasty of infrapopliteal vessels in patients with peripheral arterial disease (PAD) and critical lower limb ischemia reduces pain, claudication and infection in patients. There is a low rate of major amputations after therapy as a measure of salvage of the limb. The probability of survival of the limb at 573 days is 50%.