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.

Deep vein thrombosis in noncritically ill patients with coronavirus disease 2019 pneumonia: deep vein thrombosis in nonintensive care unit patients.

BACKGROUND: Venous thromboembolic events have been one of the main causes of mortality among hospitalized patients with coronavirus disease 2019 (COVID-19) pneumonia. The aim of our study was to describe the prevalence of deep vein thrombosis (DVT) in noncritically ill patients with COVID-19 pneumonia and correlate such observations with the thromboprophylaxis received. METHODS: We performed a prospective cohort study of 67 patients admitted to the hospital for COVID-19 pneumonia. The diagnosis was confirmed using polymerase chain reaction testing of nasopharyngeal specimens. The deep veins were examined using compression duplex ultrasonography with the transducer on B-mode. The patients were separated into two groups for statistical analysis: those receiving low-molecular-weight heparin prophylaxis and those receiving intermediate or complete anticoagulation treatment. Risk analysis and logistic regression were performed. RESULTS: Of the 67 patients, 57 were included in the present study after applying the inclusion and exclusion criteria; 49.1% were women, and the patient mean age was 71.3 years. All 57 patients had undergone compression duplex ultrasonography. Of these 57 patients, 6 were diagnosed with DVT, for an in-hospital rate of DVT in patients with COVID-19 pneumonia of 10.5%. All the patients who had presented with DVT had been receiving low-molecular-weight heparin prophylaxis. The patients receiving prophylactic anticoagulation treatment had a greater risk of DVT (16.21%; 95% confidence interval, 0.04-0.28; P = .056) compared with those receiving intermediate or complete anticoagulation treatment. We also found a protective factor for DVT in the intermediate or complete anticoagulation treatment group (odds ratio, 0.19; 95% confidence interval, 0.08-0.46; P < .05). CONCLUSIONS: Noncritically ill, hospitalized patients with COVID-19 pneumonia have a high risk of DVT despite receipt of correct, standard thromboprophylaxis.

Role of an age-adjusted D-dimer cutoff level in the diagnosis algorithm of lower limb deep venous thrombosis in outpatients.

OBJECTIVE: Our goal was to analyze the utility of the age-adjusted D-dimer cutoff value in patients with clinically suspected deep venous thrombosis (DVT) in an ambulatory care setting, including distal DVTs. METHODS: This was an observational cohort study of 606 outpatients older than 18 years presenting with low or moderate clinical suspicion of lower limb DVT (measured by Wells scale). D-dimer levels were obtained, and duplex ultrasound was performed (including femoropopliteal and below-knee veins). We calculated sensitivity, specificity, and positive and negative predictive D-dimer values and when to apply the age-adjusted D-dimer cutoff value (D-dimer threshold = age × 10 µg/L). We split patients older than 50 years into 10-year age groups. We constructed receiver operating characteristic curves of the D-dimer test for each group to find the best threshold (defined as the value of D-dimer that gives more specificity, maintaining the maximum possible sensitivity). RESULTS: There were 249 men and 357 women with a mean age of 69.3 years; 41 patients were diagnosed with DVT. At a D-dimer threshold of 250 µg/L, sensitivity was 93%, specificity was 8%, positive predictive value was 7%, and negative predictive value was 94%. When the age-adjusted cutoff level was applied, global sensitivity was 76% and specificity 61%; positive predictive value was 12%, and negative predictive value was 97%. False-negative rate was 24%. We split patients older than 50 years into 10-year age groups: 50 to 60 years, 60 to 70 years, 70 to 80 years, and >80 years. The optimum thresholds were, respectively, 526 µg/L, 442.5 µg/L, 475 µg/L, and 549. µg/L. CONCLUSIONS: In our series, the age-adjusted D-dimer cutoff level is not useful in the diagnostic algorithm of DVT.

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.