Usefulness of ultrasound-guided tibio-pedal access in patients with critical limb ischemia.

INTRODUCTION: Retrograde access performed guided by fluoroscopy or ultrasound. We aimed to analyze the usefulness of ultrasound in retrograde access in patients with critical limb ischemia. METHODS: Observational analytical study. From December 2013 to June 2019. We included all retrograde accesses that were guided by ultrasound. Our register assesses demographic and clinical data, the vessel used as retrograde access, the procedure performed, the amount of contrast agent used and time of fluoroscopy, access failure, and local complications. RESULTS: On 715 procedures performed, was used ultrasound-guided retrograde access in 25 patients (64% men). The mean age was 74.8 years (45-90), with 92% of diabetics and 32% of chronic renal failure. Two patients with Rutherford stage 4 and 23 with stage 5-6. In 24 (96%) patients the ultrasound-guided puncture was successful, while in one (4%) of them, it was not possible to enter the target vessel. After the punch, was achieved the technical success of revascularization in 19 (79.2%) patients, with 5 (20.8%) in whom did not the arterial injury was not overcome. The arteries used as retrograde access were: anterior tibial 11, posterior tibial 10, and peroneal in 4. The mean of contrast used was 63 mL (9-100 mL) with an average time of 43 min (15-76 min). Complications related did not observe in retrograde access. CONCLUSIONS: Ultrasound-guided retrograde distal access is an effective method that may use as a bailout method in those endovascular procedures in which it is not possible to cross the lesion anterogradely.

Usefulness of ultrasound-guided tibio-pedal access in patients with critical limb ischemia. / Utilidad de la ecografía en la punción retrógrada distal en la isquemia crítica de extremidades inferiores.

INTRODUCTION: Retrograde access performed guided by fluoroscopy or ultrasound. We aimed to analyze the usefulness of ultrasound in retrograde access in patients with critical limb ischemia. METHODS: Observational analytical study. From December 2013 to June 2019. We included all retrograde accesses that were guided by ultrasound. Our register assesses demographic and clinical data, the vessel used as retrograde access, the procedure performed, the amount of contrast agent used and time of fluoroscopy, access failure, and local complications. RESULTS: On 715 procedures performed, was used ultrasound-guided retrograde access in 25 patients (64% men). The mean age was 74.8 years (45-90), with 92% of diabetics and 32% of chronic renal failure. Two patients with Rutherford stage 4 and 23 with stage 5-6. In 24 (96%) patients the ultrasound-guided puncture was successful, while in one (4%) of them, it was not possible to enter the target vessel. After the punch, was achieved the technical success of revascularization in 19 (79.2%) patients, with 5(20.8%) in whom did not the arterial injury was not overcome. The arteries used as retrograde access were: anterior tibial 11, posterior tibial 10, and peroneal in 4. The mean of contrast used was 63 mL (9-100 ml) with an average time of 43 minutes (15- 76 min). Complications related did not observe in retrograde access. CONCLUSIONS: Ultrasound- guided retrograde distal access is an effective method that may use as a bailout method in those endovascular procedures in which it is not possible to cross the lesion anterogradely.

Infection of arteriovenous fistula for hemodialysis: An uncommon etiology / Infección de fístula arteriovenosa protésica para hemodiálisis de causa inusual

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Ultrasound Surveillance in Endovascular Revascularization of Lower Limbs.

BACKGROUND: Endovascular surgery has become the initial treatment for most patients with chronic ischemia of the lower limbs. Few studies support ultrasound surveillance (US) of this kind of procedures. The purpose of this study was to evaluate the initial efficacy of duplex ultrasound as a surveillance method in endovascular treatment in symptomatic peripheral arterial disease patients in our center. MATERIAL AND METHODS: A total of 113 endovascular procedures performed in 106 patients between February 2013 and June 2015 were included. Follow-up included clinical assessment, physical examination, ankle-brachial index (ABI), plethysmography, and ultrasound at 1, 3, 6, 12, 18, and 24 months after surgery. Patients without a minimum follow-up of two controls were excluded. Worsening was defined as follows: (1) in ultrasound, a restenosis >70%; (2) from ABI, a decrease >0.15; (3) clinically, a decrease in claudication distance, reappearance rest pain, or worsening injuries; (4) in plethysmography, flattening in the curve. RESULTS: The average age was 68.3 years, with 72% being men. Twenty-two percent of treated lesions were iliac, 57% were femoropopliteal, and 21% were distal. There were 329 visits, with a mean follow-up of 13.5 months (3-31). The US detected permeability or moderate stenosis in 66 patients (58.4%) and restenosis or occlusion in 47 (41.6%). When compared with clinical status, there was a noncorrelation in 23% and a discrepancy with respect to the ABI of 27% and of 39% with plethysmography. All these differences were statistically significant (P < 0.001). Twenty-one reinterventions were performed (18.6%), six patients died (5.3%), and 11 required major amputation (9.7%). CONCLUSIONS: Clinical status and hemodynamics can detect restenosis or occlusion of the procedure in a large part of the cases, but it can omit more than 20% of these that were only detected by US. The ultrasound follow-up is of great help to increase the reliability of the control in patients with endovascular revascularization of lower limbs.

Contrast-Induced Nephropathy: A Fact or Fiction in Lower Limb Revascularization?

INTRODUCTION: Contrast-induced nephropathy (CIN) is defined as an increase >25% of serum creatinine from baseline, occurring in 24-48 hours after exposure to contrast, while alternative explanations for renal impairment have been excluded. The volume administered directly relates to risk, increasing by 12% per 100 mL of contrast. According to the series, its incidence varies between 3.3% and 8% in patients without renal damage and 12-50% in patients with chronic kidney disease (CKD) and/or diabetes mellitus (DM). The purpose of this study is to determine the incidence of CIN in endovascular revascularization of lower limbs in our center, where we apply the ALARA concept (As Low As Reasonably Achievable) to the use of contrast. MATERIAL AND METHODS: 163 patients who underwent endovascular revascularization procedures in lower limbs were included in this prospective observational study between February 2013 and April 2015. They were classified according to clinical stage and presence of DM and/or CKD. Data included serum creatinine values preoperative and postoperative, type and volume of contrast used. Patients on hemodialysis and those without sufficient analytical data were excluded. Chi-squared test and Student t-test were used for data analysis. P < 0.05 was considered statistically significant. RESULTS: 109 patients were enrolled, with 67% of DM and 31.5% of CKD. CIN incidence was 3.7% in patients without DM neither CKD, in DM was 6.8% and 12.5% in CKD. Mean creatinine presurgery was 97.96 and postsurgery 97.07, finding no significant differences between them (P = 0.753). Medium-contrast volume was 37.43 mL ± 22.3. The worsening variable (creatinine postsurgery minus creatinine presurgery) was evaluated according to clinical stage, DM, or CKD, being not significant in either group. CONCLUSIONS: In our experience, the dose administered of contrast was not related to the existence of postprocedure CIN, due to the policy of optimizing the use of contrast.