Off-label use of interwoven carotid stent in common femoral artery occlusion after surgery.

Open surgery is the gold standard for treating common and deep femoral arterial lesions. Nevertheless, significant data have emerged in recent years supporting an endovascular strategy for this peculiar anatomic region, despite certain disadvantages, including the requirement for strong compression resistance and excellent flexibility and conformability when stents are implanted. We present a case of critical limb ischemia due to total common and deep femoral arteries occlusion after endarterectomy that resulted in a very tapered lesion. It was successfully treated with percutaneous angioplasty and off-label application of an interwoven nitinol Roadsaver carotid artery stent, which demonstrated good adaptability.

PBMNCs Treatment in Critical Limb Ischemia and Candidate Biomarkers of Efficacy.

When in critical limb ischemia (CLI) the healing process aborts or does not follow an orderly and timely sequence, a chronic vascular wound develops. The latter is major problem today, as their epidemiology is continuously increasing due to the aging population and a growth in the incidence of the underlying diseases. In the US, the mean annualized prevalence of necrotic wounds due to the fact of CLI is 1.33% (95% CI, 1.32-1.34%), and the cost of dressings alone has been estimated at USD 5 billion per year from healthcare budgets. A promising cell treatment in wound healing is the local injection of peripheral blood mononuclear cells (PBMNCs). The treatment is aimed to induce angiogenesis as well to switch inflammatory macrophages, called the M1 phenotype, into anti-inflammatory macrophages, called M2, a phenotype devoted to tissue repair. This mechanism is called polarization and is a critical step for the healing of all human tissues. Regarding the clinical efficacy of PBMNCs, the level of evidence is still low, and a considerable effort is necessary for completing the translational process toward the patient bed site. From this point of view, it is crucial to identify some candidate biomarkers to detect the switching process from M1 to M2 in response to the cell treatment.

Superficial Femoral Artery Access for Infrainguinal Antegrade Endovascular Interventions in the Hostile Groin: A Prospective Randomized Study.

BACKGROUND: In a hostile groin, it may be difficult to perform antegrade endovascular procedures at the lower extremities using the ipsilateral common femoral artery as vascular access; therefore, the use of the ipsilateral superficial femoral artery (SFA) could be a useful alternative. In this study, we evaluated the feasibility and safety of ultrasound-guided SFA puncture versus traditional SFA cutdown to achieve arterial access. METHODS: This prospective observational randomized study examined patients with symptomatic peripheral arterial disease who required endovascular interventions at the lower extremities. A hostile groin was defined as a high femoral bifurcation, obesity, and surgical scarring due to previous surgical interventions. A 6-Fr sheath (12 cm long; ULTIMUM EV INTRODUCER; Abbott, Plymouth, MN, USA) was used in all procedures. In the percutaneous group, the puncture was performed under ultrasound guidance and hemostasis was performed using a percutaneous closure device (PCD) (ANGIO-SEAL VIP 6-Fr; Terumo Medical Corporation, Somerset, NJ, USA). The primary end points were technical success and perioperative complications. The secondary end points were the time required for the management of vascular access and the type of anesthesia administered. RESULTS: Between 2020 and 2021, 107 patients who underwent antegrade revascularization were enrolled. SFA was achieved in 50 cases by the femoral cutdown technique (c-group) and in 57 cases by percutaneous ultrasound-guided puncture (p-group). In the c-group, the time from incision to sheath introduction and the time of suturing the artery and wound closure was 35 ± 8 min. In the p-group, the time from skin puncture and sheath placement plus that from the sheath removal and hole closure with the PCD was 6 ± 3 min. For the c-group versus p-group, the following variables were as follows: high bifurcation, 10 vs. 6 cases (P = 0.2); severe obesity, 33 vs. 40 cases (P = 0.46); and previous surgical groin interventions, 7 vs. 9 cases (P = 0.53), respectively. The technical success rates were 100% vs. 96.49% for the c-group versus p-group, respectively (P = 0.63). Two percutaneous puncture failures were managed using the cutdown technique. In the p-group, 2 postprocedural hematomas were recorded, with only one requiring surgical treatment and 2 with SFA occlusion to intravascular cap hemostatic dislocation, which were subjected to surgical revision. A total of 3 percutaneous procedures in the p-group required surgical revision versus none in the c-group (P = 0.1). Within 3 months, complications consisted of 6 cases of surgical wound complications in the c-group versus none in the p-group (P = 0.009). All procedures in the p-group versus 72% of patients in the c-group were managed with local anesthesia (P < 0.0001). CONCLUSIONS: The femoral cutdown technique seems to be a safe and successful approach for achieving vascular access in cases of hostile groin. Ultrasound-guided puncture and PCD make SFA puncture a successful and safe alternative with an acceptable complications rate. Moreover, it reduces the time required to manage vascular access and can be performed mainly under local anesthesia.

Infrared Thermography as a Diagnostic Tool for the Assessment of Patients with Symptomatic Peripheral Arterial Disease Undergoing Infrafemoral Endovascular Revascularisations.

AIM: The aim of this study was to evaluate the utility and reliability of temperature foot changes measured by infrared thermography (IRT) for the evaluation of patients with atherosclerotic peripheral arterial disease (PAD) before and after endovascular revascularisation. METHODS: This is an observational prospective study carried out on symptomatic PAD patients. Evaluations consisted of a clinical examination, duplex scan with ankle-brachial index calculation (ABI) and IRT measurements with infrared camera FLIR-ONE connected to a smartphone with android technology. Locations on the foot sampled with IRT were the anterior tibial, pedal, posterior and arcuate arteries. Results obtained with IRT on the symptomatic foot were compared to the contralateral foot and with the ABI values obtained bilaterally before and 24 h after revascularisation. RESULTS: Within one year, 40 patients were enrolled, among whom 87,5% suffered from critical limb ischaemia. In three patients, it was impossible to obtain ABI measurements because of ulcerations on the limb. Skin temperature changes obtained by IRT between the symptomatic limb and the contralateral limb had a mean difference of 1.7 °C (range: 1.1-2.2 °C), p < 0.001. There was a positive correlation between ABI and temperature values of the limb needed for treatment before revascularisation (p = 0.025; r = 0.36) and after revascularisation (p = 0.024, r = 0.31). The technical success rate was 100% in all cases, achieving a significant increase in temperature at all points of the foot analysed, with a median change of 2 °C (p < 0.001). CONCLUSION: IRT is a safe, reliable and simple application. It could be a valuable tool for the assessment of the clinical presentation and severity of foot blood perfusion in symptomatic PAD patients and the evaluation of the technical success of endovascular revascularisation. IRT might have a role in follow-up of revascularisation procedures.

Incidence, Diagnosis, Treatment, and Outcomes of True Superficial Artery Aneurysms.

BACKGROUND: True superficial femoral artery aneurysms (SFAAs) do not occur frequently but carry a high risk of limb loss when they are complicated with thrombosis, distal embolization or rupture. Large aneurysms can also exert a mass effect, compressing adjacent veins and nerves. We performed an updated review of the literature with regard to their incidence, diagnosis, treatment, and outcomes over the years. METHODS: A MEDLINE, Excerpta Medica Database (EMBASE) search of papers reporting SFAAs was conducted. Studies reported in the literature were considered for the review regardless of their nature and the number of participants. The available data regarding patient demographics, method of diagnosis, size, location, clinical presentation, therapy, and outcomes were examined. RESULTS: Searching from 1967 to the present, we identified 59 papers reporting true SFAAs. Forty-one papers were case reports with 1 case each, 9 papers with 2 cases each and 9 papers reporting case series with more than 3 cases. There was 1 study reporting data on the management of asymptomatic SFAAs. We identified 164 SFA aneurysms, and 84.4% were symptomatic. The mean age of patients at the presentation was 70.2 years (range, 27-96) and 89.4% were men. SFAAs were diagnosed earlier in patients with connective tissue disorders, with a mean age of 35 years (range, 29-43). In 60.2 % of cases are present symptoms related to mass compression, 26,8% with rupture, and 27,3% of cases with ischemic symptoms. Endovascular approach was chosen in 52.6% of SFAAs reported in the last 5 years. CONCLUSIONS: The data in the available literature are poor regarding the management of asymptomatic aneurysms, and the conclusions are based mainly on the symptomatic aneurysms reported. Most SFAAs present mainly with symptoms due to mass compression and rupture rather than ischemic symptoms. The endovascular approach is becoming more popular and could become the preferred choice.