Successful Catheter-Directed Thrombolysis for Acute Lower Limb Ischemia Secondary to COVID-19 Infection.

A 49-year-old man was admitted to his local hospital with left leg pain and breathing difficulties. He had negative nasopharyngeal polymerase chain reaction tests for severe acute respiratory syndrome coronavirus 2. Chest X-ray and Computed tomography pulmonary angiogram displayed typical coronavirus disease 2019 (COVID-19) radiological features as ground-glass opacities and bronchovascular thickening. His respiratory symptoms resolved after four days of supportive treatment, whereas his left leg became more painful and discolored. He was referred to our center with acute left leg ischemia. computed tomography angiogram revealed eccentric mural thrombus at the aortic bifurcation, extending into left common iliac and an abrupt occlusion of left popliteal, tibioperoneal, and posterior tibial arteries. He was treated with catheter-directed thrombolysis for 48-hours that achieved successful revascularization of the ischemic limb with no intervention-related complications. At six-week follow-up, he showed full recovery. Our case demonstrates that catheter-directed thrombolysis is a successful and safe treatment option in a COVID-19 patient with acute arterial occlusion.

Bypass surgery for chronic lower limb ischaemia.

BACKGROUND: Bypass surgery is one of the mainstay treatments for patients with critical lower limb ischaemia (CLI). This is the second update of the review first published in 2000. OBJECTIVES: To assess the effects of bypass surgery in patients with chronic lower limb ischaemia. SEARCH METHODS: For this update, the Cochrane Vascular Group searched its trials register (last searched October 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (last searched Issue 9, 2016). SELECTION CRITERIA: We selected randomised controlled trials of bypass surgery versus control or any other treatment. The primary outcome parameters were defined as early postoperative non-thrombotic complications, procedural mortality, clinical improvement, amputation, primary patency, and mortality within follow-up. DATA COLLECTION AND ANALYSIS: For the update, two review authors extracted data and assessed trial quality. We analysed data using odds ratio (OR) and 95% confidence intervals (CIs). We applied fixed-effect or random-effects models. MAIN RESULTS: We selected 11 trials reporting a total of 1486 participants. Six trials compared bypass surgery with percutaneous transluminal angioplasty (PTA), and one each with remote endarterectomy, thromboendarterectomy, thrombolysis, exercise, and spinal cord stimulation. The quality of the evidence for the most important outcomes of bypass surgery versus PTA was high except for clinical improvement and primary patency. We judged the quality of evidence for clinical improvement to be low, due to heterogeneity between the studies and the fact that this was a subjective outcome assessment and, therefore, at risk of detection bias. We judged the quality of evidence for primary patency to be moderate due heterogeneity between the studies. For the remaining comparisons, the evidence was limited. For several outcomes, the CIs were wide.Comparing bypass surgery with PTA revealed a possible increase in early postinterventional non-thrombotic complications (OR 1.29, 95% CI 0.96 to 1.73; six studies; 1015 participants) with bypass surgery, but bypass surgery was associated with higher technical success rates (OR 2.26, 95% CI 1.49 to 3.44; five studies; 913 participants). Analyses by different clinical severity of disease (intermittent claudication (IC) or CLI) revealed that peri-interventional complications occurred more frequently in participants with CLI undergoing bypass surgery than PTA (OR 1.57, 95% CI 1.09 to 2.24). No differences in periprocedural mortality were identified (OR 1.67, 95% CI 0.66 to 4.19; five studies; 913 participants). The primary patency rate at one year was higher after bypass surgery than after PTA (OR 1.94, 95% CI 1.20 to 3.14; four studies; 300 participants), but this difference was not shown at four years (OR 1.15, 95% CI 0.74 to 1.78; two studies; 363 participants). No differences in clinical improvement (OR 0.65, 95% CI 0.03 to 14.52; two studies; 154 participants), amputation rates (OR 1.24, 95% CI 0.82 to 1.87; five studies; 752 participants), reintervention rates (OR 0.76, 95% CI 0.42 to 1.37; three studies; 256 participants), or mortality within the follow-up period (OR 0.94, 95% CI 0.71 to 1.25; five studies; 961 participants) between surgical and endovascular treatment were identified. No differences in subjective outcome parameters, indicated by quality of life and physical and psychosocial well-being, were reported. The hospital stay for the index procedure was reported to be longer in participants undergoing bypass surgery than in those treated with PTA.In the single study (116 participants) comparing bypass surgery with remote endarterectomy of the superficial femoral artery, the frequency of early postinterventional non-thrombotic complications was similar in the treatment groups (OR 1.11, 95% CI 0.53 to 2.34). No mortality within 30 days of the index treatment or during stay in hospital in either group was recorded. No differences were identified in patency (OR 1.66, 95% CI 0.79 to 3.46), amputation (OR 1.70, 95% CI 0.27 to 10.58), and mortality rates within the follow-up period (OR 1.66, 95% CI 0.61 to 4.48). Information regarding clinical improvement was unavailable.No differences in major complications (OR 0.66, 95% CI 0.34 to 1.31) or mortality (OR 2.09, 95% CI 0.67 to 6.44) within 30 days of treatment between surgery and thrombolysis (one study, 237 participants) for chronic lower limb ischaemia were identified. The amputation rate was lower after bypass surgery (OR 0.10, 95% CI 0.01 to 0.80). No differences in late mortality were found (OR 1.56, 95% CI 0.71 to 3.44). No data regarding patency rates and clinical improvement were reported.Technical success resulting in blood flow restoration was higher after bypass surgery than thromboendarterectomy for aorto-iliac occlusive disease (one study, 43 participants) (OR 0.01, 95% CI 0 to 0.17). The periprocedural mortality (OR 0.33, 95% CI 0.01 to 8.65), follow-up mortality (OR 3.29, 95% CI 0.13 to 85.44), and amputation rates (OR 0.47, 95% CI 0.08 to 2.91) did not differ between treatments. Clinical improvement and patency rates were not reported.Comparing surgery and exercise (one study, 75 participants) did not identify differences in early postinterventional complications (OR 7.45, 95% CI 0.40 to 137.76) and mortality (OR 1.55, 95% CI 0.06 to 39.31). The remaining primary outcomes were not reported. There was no difference in maximal walking time between exercise and surgery (1.66 min, 95% CI -1.23 to 4.55).Regarding comparisons of bypass surgery with spinal cord stimulation for CLI, there was no difference in amputation rates after 12 months of follow-up (OR 4.00, 95% CI 0.25 to 63.95; one study, 12 participants). The remaining primary outcome parameters were not reported. AUTHORS' CONCLUSIONS: There is limited high quality evidence for the effectiveness of bypass surgery compared with other treatments; no studies compared bypass to optimal medical treatment. Our analysis has shown that PTA is associated with decreased peri-interventional complications in participants treated for CLI and shorter hospital stay compared with bypass surgery. Surgical treatment seems to confer improved patency rates up to one year. Endovascular treatment may be advisable in patients with significant comorbidity, rendering them high risk surgical candidates. No solid conclusions can be drawn regarding comparisons of bypass surgery with other treatments because of the paucity of available evidence. Further large trials evaluating the impact of anatomical location and extent of disease and clinical severity are required.

Appendiceal endometriosis and carcinoid presented as acute appendicitis in pregnancy: a rare case report and review of the literature.

A 22-year-old pregnant woman presented at the twenty-seventh week of gestation in the Emergency Department with acute abdominal pain and right iliac fossa tenderness. Urgent MRI was done and was suggestive of acute appendicitis. A laparoscopy was performed that confirmed an inflamed and purulent appendix that was removed. The technique used is described in detail. The histopathologic findings were those of acute appendicitis, carcinoid, and endometriosis of the appendix. We report the first case of this extremely rare triad presented in pregnancy.

Appendiceal torsion associated with undescended caecum: a case report and review of the literature.

Torsion of the vermiform appendix is a rare disorder that causes symptoms similar to those of acute appendicitis. Primary and secondary causes of appendiceal torsion have been reported in the literature. Laparoscopy appears to be the most appropriate modality for diagnosis and treatment where the condition is suspected. To our knowledge this is the first case of appendiceal torsion in an adult causing right upper quadrant pain related to caecal malposition.

Common polymorphisms of Fibulin-5 and the risk of abdominal aortic aneurysm development.

Fibulin-5 is a crucial protein in the connective tissue structure of the aortic wall. The purpose of this study was to determine if genetic variation within the Fibulin-5 gene was associated with abdominal aortic aneurysms (AAA). AAA patients, with disease-free controls, were recruited and a past medical history questionnaire completed. Three single nucleotide polymorphisms (SNPs) in the FBLN5 gene (rs2498834, rs2430366 and rs2254320) were genotyped. The two cohorts were compared and haplotype analysis performed. A total of 230 AAA cases and 278 controls were successfully genotyped. The mean age was 71.9 years (+/- 6.8). No difference between cases and controls was found in the distribution of alleles of FBLN5 SNPs rs2498834 (p = 0.47), rs2430366 (p = 0.45) or rs2254320 (p = 0.46). Haplotype analysis did not reveal any significant difference. In conclusion, genetic variation within FBLN5 is unlikely to play any role in the development of AAA.

The effects of abdominal compartment hypertension after open and endovascular repair of a ruptured abdominal aortic aneurysm.

OBJECTIVE: This study assessed if emergency endovascular repair (eEVR) reduces the increase in intra-abdominal compartment pressure and host inflammatory response in patients with ruptured abdominal aortic aneurysm (AAA). METHODS: Thirty patients with ruptured AAA were prospectively recruited. Patients were offered eEVR or emergency conventional open repair (eOR) depending on anatomic suitability. Intra-abdominal pressure was measured postoperatively, at 2 and 6 hours, and then daily for 5 days. Organ dysfunction was assessed preoperatively by calculating the Hardman score. Multiple organ dysfunction syndrome, systemic inflammatory response syndrome, and lung injury scores were calculated regularly postoperatively. Hematologic analyses included serum urea and electrolytes, liver function indices, and C-reactive protein. Urine was analyzed for the albumin-creatinine ratio. RESULTS: Fourteen patients (12 men; mean age, 72.2 +/- 6.2 years) underwent eEVR, and 16 (14 men; mean age, 71.4 +/- 7.0 years) had eOR. Intra-abdominal pressure was significantly higher in the eOR cohort compared with the eEVR group. The eEVR patients had significantly less blood loss (P < .001) and transfused (P < .001) and total intraoperative intravenous fluid infusion (P = .001). The eOR group demonstrated a greater risk of organ dysfunction, with a higher systemic inflammatory response syndrome score at day 5 (P = .005) and higher lung injury scores at days 1 and 3 (P = .02 and P = .02) compared with eEVR. A significant correlation was observed between intra-abdominal pressure and the volume of blood lost and transfused, amount of fluid given, systemic inflammatory response syndrome score, multiple organ dysfunction score, lung injury score, and the length of stay in the intensive care unit and hospital. CONCLUSION: These results suggest that eEVR of ruptured AAA is less stressful and is associated with less intra-abdominal hypertension and host inflammatory response compared with eOR.

The vascular and biochemical effects of cilostazol in diabetic patients with peripheral arterial disease.

OBJECTIVES: Cilostazol improves walking in patients with peripheral arterial disease (PAD). We hypothesized that cilostazol reduces diabetic complications in PAD patients. METHODS: Diabetic PAD patients were prospectively recruited to a randomized double-blinded, placebo-controlled trial, using cilostazol 100mg twice a day. Clinical assessment included ankle-brachial index, arterial compliance, peripheral transcutaneous oxygenation, treadmill walking distance and validated quality of life (QoL) questionnaires. Biochemical analyses included glucose and lipid profiles. All tests were at baseline, 6, and 24 weeks. RESULTS: 26 diabetic PAD patients (20 men) were recruited. Cilostazol improved absolute walking distance at 6 and 24 weeks (86.4% vs. 14.1%, P = .049; 143% vs. 23.2%, P = .086). Arterial compliance and lipid profiles improved as did some QoL indices for cilostazol at 6 and 24 weeks. Blood indices were similar at baseline and at follow-up points for both treatment groups. CONCLUSIONS: Cilostazol is a well-tolerated and efficacious treatment, which improves claudication distances in diabetic PAD patients with further benefits in arterial compliance, lipid profiles, and QoL.

The effects of cilostazol on peripheral neuropathy in diabetic patients with peripheral arterial disease.

BACKGROUND: Evidence from diabetic animal models suggests that cilostazol, a cyclic AMP phosphodiesterase inhibitor used in the treatment of claudication, is efficacious in the treatment of peripheral neuropathy, although this is unproven in humans. The main aim of this study was to assess the effects of cilostazol on neuropathic symptomatology in diabetic patients with peripheral arterial disease (PAD). METHODS: Diabetic patients with PAD were prospectively recruited to a randomized double-blinded placebo-controlled trial. Baseline clinical data were recorded prior to trial commencement following medical optimization. Neurological assessment included the Toronto Clinical Neuropathy Scoring system (TCNS) and vibration perception thresholds (VPT) with a neurothesiometer at baseline, 6 weeks, and 24 weeks. RESULTS: Twenty-six patients were recruited from December 2004 to January 2006, which included 20 males. Baseline patient allocation to treatment arms was matched for age, sex, and medical comorbidities. There was no significant difference in neurological assessment between the treatment groups using the TCNS and VPT at 6 and 24 weeks. CONCLUSIONS: Despite extensive animal-based evidence that cilostazol attenuates neuropathic symptomatology, our results do not support this effect in human diabetic PAD patients.

Effect of preoperative renal dysfunction on mortality and postoperative renal failure following endovascular abdominal aortic aneurysm repair.

This study was aimed to assess the effect of preoperative renal dysfunction on mortality and postoperative renal failure in patients undergoing elective endovascular repair of abdominal aortic aneurysm. A total of 155 patients with a mean age of 74.9 years (+/-6.4) were included. In all, 31 patients (20%) had a preoperative creatinine level of >1.5 mg/dL, whereas 66 patients (42.6%) had an estimated glomerular filtration rate of <60 mL/min. Perioperative mortality was 2.6% with no significant difference between those with and without abnormal renal indices. Long-term survival at 4 years was 30% in patients with creatinine >1.5 mg/dL compared to over 60% in those with normal creatinine (P < .02). The difference in long-term survival was not as significant in patients with normal or reduced glomerular filtration rate (P = .13). However, neither creatinine nor glomerular filtration rate were found to accurately predict survival even though both demonstrated strong predictivity for postoperative renal failure in patients undergoing elective endovascular repair of abdominal aortic aneurysm.

Endovascular treatment of bleeding external iliac artery pseudo-aneurysm following control of haemorrhage with Sengstaken tube during revision total hip arthroplasty.

We report a case of false aneurysm of the external iliac artery and compression of the external iliac vein, which subsequently caused deep venous thrombosis in a 63-year-old female patient with a revised total hip arthroplasty. This is the first case of control of life-threatening intraoperative haemorrhage of an external iliac pseudo-aneurysm by Sengstaken tube which allowed time for successful management of the external iliac artery pseudo-aneurysm with endovascular covered stent. Recognition of delayed vascular injury following revision of total hip arthroplasty and the need of pre-operative imaging should be considered in revision hip arthroplasty.

An intention-to-treat by endovascular repair policy may reduce overall mortality in ruptured abdominal aortic aneurysm.

OBJECTIVE: The use of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (AAA) has been restricted to a small number of specialized units on a selected group of patients. The aim of this study is to assess if the overall mortality in these patients with ruptured AAA may be reduced in a unit where all patients with ruptured AAA are considered first for EVAR. METHODS: During a 24-month period beginning in July 2002, 51 patients admitted with ruptured AAA were considered for EVAR as the treatment of choice and comprised the study group. EVAR was performed in 17 patients. Open repair was performed in 34 patients: 13 patients had hemodynamic instability and 16 patients had an unsuitable aortic neck anatomy. The study group was compared with a historical control group of 41 patients with ruptured AAA who were treated by open repair from July 2000 to June 2002. RESULTS: Mortality rate was 39% in the study group compared with 59% in the control group (P = .065). The duration of stay in the intensive care unit was significantly lower in the study group than in the control group (P = .01), although the total in-hospital stay was similar (17 days vs 14 days, P = .83). Within the study group, EVAR patients had a mortality rate of 24% compared with 47% in the open group (P = .14). CONCLUSION: Although the number of patients was small, offering EVAR to as many patients as possible with ruptured AAA has resulted in a 20% reduction in mortality, albeit statistically insignificant. However, it is in the unstable patients that EVAR will need to improve survival before it may be hailed to supersede the conventional approach.

Aortic necks of ruptured abdominal aneurysms dilate more than asymptomatic aneurysms after endovascular repair.

BACKGROUND: Endovascular repair of abdominal aortic aneurysm (AAA) is increasingly used. We evaluated if a difference exists in the rate of change of the aortic neck diameter between non-ruptured and ruptured AAAs after endovascular aneurysm repair (EVAR). METHODS: Details of patients undergoing elective (group I) and emergency (group II) EVAR using Talent stents between October 1999 and September 2005 were reviewed. Top neck diameters were prospectively recorded on the hospital database from computed tomography scans preoperatively and at 1, 3, 12, and 24 months postoperatively. The aortic neck diameter rate of change was calculated for each group. RESULTS: Endovascular repair was performed on 110 elective and 41 emergency patients, of which 100 (80 male) elective and 29 (26 male) emergency patients were included in this analysis. Mean age was similar in each group. Stents were oversized by 20.9% +/- 13.6% in group I and by 24.7% +/- 16.3% in group II (P = .37). The preoperative mean proximal aortic neck was larger in group II (25.0 +/- 3.3 mm vs 23.5 +/- 2.8 mm; P = .029). The growth rate of the top neck diameter was significantly greater at 12 months (1.48 +/- 2.4 mm/year vs 3.89 +/- 6.24 mm/year; P = .04) and 24 months (.99 +/- 1.1 mm/year vs 2.61 +/- 3.3 mm/year; P = .04) in group II than in group I. A decreasing sac size was found in 68.2% of patients whose neck dilated. The complication rate was similar in each group. CONCLUSION: Aneurysm necks in patients with ruptured aneurysms are larger and dilate at a greater rate than those with nonruptured aneurysms. The accelerated rate of expansion in some patients must be borne in mind during follow-up and in secondary endovascular interventions and conversion to open surgery.

Techniques in occluding the aorta during endovascular repair of ruptured abdominal aortic aneurysms.

Among various methods to achieve rapid occlusion of the aorta during endovascular repair for ruptured abdominal aortic aneurysm, particular emphasis is placed on two techniques that have been incorporated into our endovascular repair practice. The sheath-over-balloon technique (the Loan SOB technique) facilitates hemodynamic stability by transfemoral endovascular placement of an aortic occlusion balloon catheter to the infrarenal abdominal aorta. The balloon-ahead-of-graft technique (the Hornsby BAG technique) allows suprarenal hemodynamic control using a stent-graft system with a built-in balloon. The two techniques are simple, quick, and effective in achieving hemodynamic stability.