Long-term functional outcomes and subclavian vein patency in patients undergoing thoracic outlet surgery for Paget-Schroetter Syndrome.

BACKGROUND: To assess subclavian vein (SCV) patency and long-term functional outcomes following surgical decompression of the thoracic outlet (SDTO) for Paget-Schroetter Syndrome (PSS). METHODS: Between January 1978 and January 2013, we identified 33 patients with PSS who underwent SDTO. Demographic, clinical and radiological data were extracted from electronic databases and patient records. All patients were invited to update their follow-up data during dedicated outpatient visits between October and December 2013. Outcome measures included long-term SCV patency and clinical success rates during follow-up. Clinical success was defined as the combined absence of functional symptoms and patient's ability to maintain normal professional activities at final follow-up. The QuickDASH score was also determined. RESULTS: The study population comprised 17 men and 16 women (mean age 34 years; range: 14-53 years) with PSS. Diagnosis was reached by venography (29 cases) or duplex scan (4 cases). SDTO was performed via the transaxillary route (25 cases) or using the combined supra-infraclavicular approach (8 cases). The procedure was carried out within 10 days in 13 patients (early-group), and between 30 to 120 days in the remaining 20 patients (late-group). The former had SCV recanalization obtained actively by thrombolysis (3 cases), thrombectomy (9 cases) or endovenectomy followed by patch venoplasty (1 case). The latter were maintained under chronic oral anticoagulation to allow SCV recanalization. There was neither postoperative death nor major bleeding complications. At a median follow-up of 240 months, 11 SCV remained patent in the early group, while in the other there was 3 re-occlusions, 4 residual stenoses and 5 chronic SCV occlusions. Clinical success was achieved in 73% of patients for the whole cohort, but was significantly better in patients operated on in the early stages (100% vs. 55%; P=0.005). The mean Quick Disabilities of the Arm, Shoulder, and Hand Score was 3.5 (95% CI: 1.5-5.4) in the early-group and 17.3 (95% CI: 8.4-26.2) in the late-group (P=0.01). CONCLUSIONS: Our data shows that long-term functional outcomes and SCV patency remained better in PSS patients who underwent early SDTO and active SCV recanalization techniques.

Pelvic ischemia and quality of life scores after interventional occlusion of the hypogastric artery in patients undergoing endovascular aortic aneurysm repair.

OBJECTIVE: The aim of this study was to analyze the pelvic ischemic complications and their impact on quality of life after interventional occlusion of the hypogastric artery (IOHA) in patients undergoing endovascular aortic aneurysm repair (EVAR). METHODS: Between January 2004 and April 2012, 638 consecutive patients with aortoiliac aneurysm treated by EVAR were prospectively registered in two teaching hospitals. We identified all EVAR patients who underwent IOHA. Demographic, clinical, and radiologic data were extracted from electronic databases and patient records as requested. All patients who survived the postoperative period took part in a quality of life survey, the Walking Impairment Questionnaire (WIQ), which included four items: pain, distance, walking speed, and stair climbing. Outcome measures included the 30-day rate of pelvic ischemic complications, the buttock claudication (BC) rate at 30 days and during follow-up, and the comparative WIQ scores between patients with persistent BC, those with regressive BC, and those who never had BC after the IOHA procedure. RESULTS: A total of 71 patients (97% men; mean age, 76 years ± 7.69) required 75 IOHA procedures. These were deemed proximal in 44 cases and distal in 31, with use of coil embolization in 64%, Amplatzer plug in 24%, or a combination of coils and plugs in 12%. The technical success rate was 100%. Two patients (2.8%) experienced fatal acute pelvic ischemic complications in the postoperative period after EVAR. Another patient died of iliac rupture during EVAR, leading to an operative mortality rate of 4.3%. Eighteen patients (25.3%) suffered BC, among whom 11 cases resolved at a median follow-up of 42 months. Young age (odds ratio, 0.92; 95% confidence interval, 0.85-0.99; P = .03) and distal IOHA (odds ratio, 3.5; 95% confidence interval, 1.01-11.51; P = .04) were independent predictors of BC occurrence. The actuarial rate of persistent BC was 85% at 18 months. The WIQ scores were lower for patients with persistent BC (median score, 35.04; interquartile range, 16.36; P = .001) compared with patients with regressive BC (median score, 76.5; interquartile range, 36.66; P = .02) or those who never experienced BC after the IOHA procedure (median score, 65.34; interquartile range, 10.94; P < .0003). CONCLUSIONS: Pelvic ischemia associated with IOHA may be severe and lead to fatality after EVAR. Our data show that BC may lead to severe quality of life impairment when it does not regress during follow-up.

Percutaneous angioplasty of long tibial occlusions in critical limb ischemia.

BACKGROUND: The aim of this study was to assess the midterm results of percutaneous angioplasty in patients with critical limb ischemia (CLI) and long tibial occlusions. METHODS: Between January and September 2011, 34 consecutive patients with patent femoropopliteal artery and 49 segmental tibial occlusions >8 cm were included in our prospective, single-center cohort study. Clinical success (defined as wound healing and survival without major amputation), patency, and freedom from target vessel revascularization (TVR) were examined. RESULTS: The median age of the patients was 75 (53-89) years, 74% were diabetic, and 89% of the limbs studied were Rutherford 5 and 6. Median follow-up was 12.5 (1-15) months. The 1-year clinical success rate was 65%, higher among patients with technical success (76% vs. 25%, P = 0.01) and patients with 2 or 3 patent tibial arteries after the procedure (90% vs. 41% in patients with only 1 patent artery, P = 0.003). At 1 year, primary and secondary patency rates were 13% and 32%, respectively (24% and 58% without technical failures). The 1-year freedom-from-TVR rate was 34%. CONCLUSIONS: Despite high technical failure rates and the need for repeat procedures, percutaneous angioplasty of long tibial occlusions enhances wound healing, especially when integrated into a maximal revascularization approach.

Subintimal recanalization of femoropopliteal occlusive lesions in patients with critical ischemia: 66 cases.

BACKGROUND: Subintimal recanalization allows for the treatment of percutaneously extended occlusive lesions. The aim of this study was to evaluate the feasibility and short- and mid-term results of subintimal recanalization in the treatment of femoropopliteal occlusive lesions in patients with critical ischemia. METHODS: Between January 2009 and December 2010, consecutive patients with critical ischemia presenting with femoropopliteal arterial occlusion were included in this study. These patients underwent subintimal recanalization, and all patients had clinical and ultrasound follow-up. RESULTS: Sixty-six procedures were performed on 66 patients (mean age, 79±10 yrs). All patients were American Society of Anesthesiologists classification 3 or 4. Thirty-two patients had diabetes and 27 had chronic renal insufficiency. More than two-thirds (76%) of the lesions had a Trans-Atlantic Inter-Society Classification of C or D. The mean occlusion length was 13.5±7 cm. The rate of technical success was 85%. The peroperative complication rate was 4.5%. There were no cases of operative mortality. Occlusion length was the only predictive factor of restenosis (P=0.049). At 1 year, primary and secondary patency rates were 56% and 70%, respectively, for a 92% rate of limb salvage. CONCLUSION: The subintimal recanalization technique is feasible and minimally invasive. At 1 year postprocedure, the primary patency is poor, but this technique is associated with a high rate of limb salvage. It is suitable for the treatment of critical ischemia, taking into account the often precarious clinical backgrounds of these patients.