Arterialização venosa superficial com veia safena magna in situ: a experiência de um único centro / Superficial venous arterialization with the great saphenous vein in situ: a single-center experience

Resumo Contexto A arterialização do arco venoso dorsal do pé é uma técnica indicada em casos de isquemia crítica de membros inferiores sem leito distal adequado que possibilite tratamento convencional, como revascularização, angioplastia ou tratamento clínico. Objetivos O propósito do trabalho foi apresentar o resultado da arterialização do arco venoso do pé em 16 pacientes submetidos a essa técnica. Métodos Tratou-se de um estudo analítico descritivo retrospectivo transversal, baseado na revisão de prontuários de 16 pacientes submetidos à arterialização do arco venoso dorsal do pé para salvamento de membro, entre janeiro de 2016 a janeiro de 2021. Resultados Dos 16 pacientes submetidos à arterialização do arco venoso do pé, 25% (4) evoluíram para amputação maior durante a mesma internação, e 6,25% (1) pacientes evoluíram para amputação maior após 6 meses. Os demais pacientes (68,75%, 11) tiveram seus membros preservados, sendo que 10 foram submetidos a amputações menores (pododáctilos e antepé), e 1 paciente não necessitou de procedimento adicional. Conclusões A técnica de arterialização do arco venoso dorsal do pé deve ser considerada em casos selecionados. Trata-se de uma alternativa válida para a preservação do membro na impossibilidade de tratamento convencional.

Abstract Background Arterialization of the dorsal venous arch of the foot is a technique indicated in cases of critical lower limb ischemia that do not have a distal bed that is adequate to enable conventional treatment such as revascularization, angioplasty, or clinical treatment. Objectives The purpose of this study is to present the result of arterialization of the venous arch of the foot in 16 patients who underwent treatment with this technique. Methods This is a cross-sectional retrospective descriptive analytical study based on a review of the medical records of 16 patients who underwent arterialization of the dorsal venous arch of the foot for limb salvage from January 2016 to January 2021. Results Four (25%) of the 16 patients who underwent arterialization of the venous arch of the foot underwent a major amputation during the same hospital stay and one patient (6.25%) had a major amputation within 6 months. The other 11 patients (68.75%) had their limbs preserved, with 10 undergoing minor amputations (toes and forefoot) and one patient having no additional procedures. Conclusions We conclude that the technique of arterialization of the dorsal venous arch of the foot should be considered in selected cases. It is a valid alternative for limb salvage when conventional treatment is impossible.

Prognostic relevance of female gender on mortality after peripheral artery disease revascularization / Relevancia pronóstica del género femenino en la mor talidad luego de la revascularización de la enfermedad arterial periférica

Abstract Introduction : Lower limb peripheral artery disease (PAD) presents high morbidity and mortality. Women represent a small subgroup in different studies, with scarce evidence regarding the prognosis of this gender on PAD. The aim of the present work was to determine the prognostic impact of female gender on lower limb PAD revascularization. Methods : This was a retrospective, single-center study, including patients undergoing symptomatic lower limb PAD revascularization. Results : Among a total of 309 patients included in the study, 109 belonged to the female gender (35%). Women were older and presented lower prevalence of cardiovascular risk factors compared with the male gender. All-cause mortality (22% vs. 12%, p = 0.02) and re-hospitalizations for chronic limb-threatening ischemia (18% vs. 10%, p = 0.04) rates were significantly higher in women. In a multivariate regression model, female gender was independently associated with all-cause mortality (OR 2.19 [95% CI: 1.06-4.51], p = 0.03). The time-to-event showed that women exhibited 93% more risk of suffering death than men, after adjusting for clinically relevant variables (HR 1.93 [95% CI: 1.04-3.56], p = 0.04). Discussion : Women with symptomatic PAD revascu larization presented worse prognosis than men in terms of all-cause mortality and re-hospitalizations for chronic limb-threatening ischemia rates. Therefore, it is essen tial to achieve an adequate control of cardiovascular risk factors, as well as to optimize medical treatment in female patients.

Resumen Introducción : La enfermedad arterial de miembros inferiores (EAMI) presenta elevada morbimortalidad. Las mujeres constituyen un subgrupo minoritario en distin tos estudios, con escasa evidencia acerca del pronóstico por género en EAMI. Nuestro objetivo fue determinar el impacto pronóstico del género femenino en la revascu larización de EAMI. Métodos : Estudio de cohorte retrospectivo y unicén trico, que incluyó pacientes con EAMI sintomática y revascularizada. Resultados : Se incluyeron 309 pacientes, de los cuales 109 (35%) eran mujeres. Las mujeres fueron más añosas y presentaron menor prevalencia de factores de riesgo cardiovascular en comparación a los hombres. Las tasas de mortalidad por todas las causas (22% vs. 12%, p = 0.02) y de hospitalizaciones por isquemia crítica (18% vs. 10%, p 0.04) fueron significativamente mayores en mujeres. En el modelo de regresión multivariado, el sexo femenino se asoció de forma independiente con mortalidad por todas las causas (OR 2.19 [IC 95%: 1.06-4.51], p = 0.03). En el análisis de tiempo al evento, las mujeres tuvieron 93% más riesgo de morir que los hombres, luego de ajustar por variables clínicamente relevantes (HR 1.93 [IC 95%: 1.04-3.56], p = 0.04). Discusión : Las mujeres con EAMI sintomática y re vascularizada presentaron un peor pronóstico en com paración a los hombres en términos de tasas de mor talidad por todas las causas y de hospitalizaciones por isquemia crítica de miembros inferiores. Por lo tanto, es fundamental lograr un adecuado control de factores de riesgo cardiovascular, como así también, optimizar el tratamiento médico en el género femenino.

Clinical impact of the infrapatellar location in symptomatic peripheral arterial disease patients / Impacto clínico de la localización infrapatelar en pacientes con enfermedad arterial periférica sintomática

Abstract Background: Peripheral artery disease (PAD) frequently affects multiple segments of the limbs. Contradictory data have reported worse prognosis in aortoiliac lesions, nevertheless, diabetes and chronic limb ischemia frequently affects the infrapatellar territory. Our aim was to assess the impact of infrapatellar disease in cardiovascular outcomes. Methods: We performed a retrospective, observational cohort study at a university hospital in Argentina. Electronic health records were retrospectively reviewed including symptomatic PAD patients requiring revascularization. A multivariable regression model was performed to account for confounders. The primary endpoint was a composite of hospitalizations due to chronic limb threatening ischemia (CLTI) and major amputation events between infrapatellar and suprapatellar patients. Minor amputation events, all-cause death, myocardial infarction (MI), stroke, and major cardiovascular events (MACE) were secondary endpoints. Results: From January 2014 through July 2020, a total of 309 patients were included in the analysis. 151 patients had suprapatellar disease, and 158 had infrapatellar disease. The primary composite endpoint occurred in 35 patients (22.2%) in the infrapatellar patients and 18 patients (11.9%) in the suprapatellar patients (HR = 2.16; 95% confidence interval [CI] = [1.22-3.82]; p = 0.008). Both components of the primary outcomes occurred more frequently in infrapatellar patients. Minor amputation events were more prevalent in infrapatellar patients (HR = 5.09; 95% CI = [1.47-17.6]; p = 0.010). Death, MI, stroke, and MACE events were not different among groups (all p > 0.05). Conclusion: Infrapatellar disease was an independent factor for increased hospitalization of CLTI, major and minor amputations events, compared to suprapatellar disease in symptomatic revascularized PAD patients.

Resumen Objetivo: La enfermedad vascular periférica (EVP) afecta generalmente múltiples segmentos de los miembros. Existe información contradictoria con respecto al pronóstico de pacientes con enfermedad aortoilíaca, sin embargo, la diabetes y la enfermedad critica de miembros inferiores habitualmente afecta el territorio infrapatelar. Nuestro objetivo es determinar el impacto de la afectación infrapatelar en eventos cardiovasculares. Métodos: Estudio retrospectivo, observacional en un hospital universitario de Argentina. Se revisó la historia clínica electrónica de pacientes con EVP con requerimiento de revascularización. Se generó un modelo de regresión multivariado incluyendo variables clínicamente relevantes. El punto final primario fue un combinado de hospitalización por isquemia crítica y amputaciones mayores entre pacientes con afectación infrapatelar y suprapatelar. Amputaciones menores, muerte por todas las causas, infarto agudo de miocardio (IAM), accidente cerebrovascular (ACV) y un combinado de eventos cardiovasculares (MACE) fueron los puntos secundarios. Resultados: Se reclutó un total de 309 pacientes desde enero de 2014 hasta julio de 2020. 151 pacientes presentaron enfermedad suprapatelar y 158 infrapatelar. El punto final primario ocurrió en 35 pacientes (22.2%) en el grupo infrapatelar y en 18 pacientes (11.9%) en suprapatelares (HR 2.16; intervalo de confianza 95% [1.22-3.82]; p = 0.008). Ambos componentes ocurrieron con mayor frecuencia en pacientes con afectación infrapatelar. Los eventos de amputación menor fueron mas prevalentes en pacientes con afectación infrapatelar (HR 5.09; IC95% [1.47-17.6]; p = 0.010) La mortalidad por todas las causas, IAM, ACV y MACE no fueron diferentes entre los grupos (p > 0.05). Conclusión: La enfermedad infrapatelar fue un factor independiente para mayor riesgo de hospitalización por isquemia critica, amputación mayor y menor comparado con pacientes con afectación suprapatelar en EVP sintomática revascularizada.

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

Introducción La punción retrógrada se puede realizar guiada mediante fluoroscopia o ecografía. Nuestro objetivo fue analizar la utilidad de la ecografía en la punción retrógrada distal de las extremidades inferiores. Métodos Estudio analítico observacional de diciembre del 2013 a junio del 2019. Se incluyeron todos los accesos retrógrados distales que fueron realizados guiados ecográficamente. Se analizaron datos demográficos y clínicos, vaso utilizado como acceso retrógrado, procedimiento efectuado, cantidad de contraste usada y tiempo de escopia, fallo en el acceso y complicaciones locales. Resultados De 715 procedimientos, se utilizó el acceso retrógrado ecoguiado en 25 pacientes (64% hombres). La edad media fue de 74,8 años (45 a 90), con un 92% de diabéticos y un 32% de insuficiencia renal crónica. La clínica inicial era estadio 4 de Rutherford en dos pacientes y estadios 5-6 en los restantes 23. En 24 (96%) pacientes la punción ecoguiada fue satisfactoria, mientras que en un caso (4%) no se consiguió entrar en el vaso diana. Posteriormente a la punción, el éxito técnico de la revascularización fue conseguido en 19 (79,2%) pacientes, con cinco (20,8%) en los que no se consiguió superar la lesión. Las arterias utilizadas como acceso retrógrado fueron: tibial anterior 11, tibial posterior 10 y peronea en cuatro. Se utilizó una media de 63mL (9 a 100 mL) de contraste con un tiempo medio de escopia de 43 minutos (15 a 76 min). No se observaron complicaciones relacionadas con el acceso retrógrado. Conclusiones El acceso retrógrado distal ecoguiado es un método seguro y efectivo, que supone un buen recurso en aquellos procedimientos endovasculares en los que no es posible su realización vía anterógrada (AU)

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 (AU)

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.

Resultados en el corto y mediano plazo del tratamiento endovascular en la enfermedad arterial obstructiva infrapoplítea en pacientes con isquemia crítica de una extremidad / Short to midterm results after endovascular approach in critical limb isquemia in patients with below-the-knee arterial disease

Resumen Objetivo: Mostrar los resultados en el corto y mediano plazo del tratamiento endovascular de angioplastia transluminal percutánea (ATP) con balón en pacientes en estado de isquemia crítica por enfermedad arterial obstructiva infrapoplítea. Materiales y Método: Estudio descriptivo, observacional, retrospectivo. Se incluyeron los pacientes hospitalizados entre 2009 y 2018 por isquemia crítica Fontaine III o IV sometidos a una ATP del territorio infrapoplíteo. Se observó como objetivos primarios la preservación de la extremidad afectada y la mortalidad posoperatoria a un año plazo, y como objetivos secundarios los procedimientos adicionales en pacientes con lesiones o necrosis distales, estadía hospitalaria, complicaciones posoperatorias y necesidad de reintervención. Resultados: Se incluyeron 42 pacientes con un promedio de edad de 66 años (46-82), con importantes comorbilidades. Un 83,3% ingresó en etapa Fontaine IV. En 16 casos se realizó una angioplastia percutánea en más de una arteria. No se colocó stents. Se presentaron complicaciones en 3 pacientes, 2 requirieron una amputación mayor y en otro se debió efectuar un nuevo procedimiento endovascular de rescate. La estadía hospitalaria promedio fue 22 días. No hubo mortalidad precoz posprocedimiento. La mortalidad global a un año fue 9,5%. A todos los pacientes en etapa Fontaine IV se les efectuó algún procedimiento adicional, a 31 una amputación menor, 3 cerraron sus lesiones por segunda intención y en otro se realizó un injerto dermo-epidérmico. De los 35 pacientes con seguimiento, 77% preservó su extremidad a un año. Conclusión: La reparación endovascular mediante una angioplastia percutánea en estos casos es un procedimiento seguro y tiene una alta tasa de preservación de la extremidad inicial a un año de seguimiento.

Aim: Show initial and midterms results of endovascular Percutaneous Transluminal Angioplasty (PTA) in critical limb isquemia (CLI) patients caused by below-the-knee arterial disease. Materials and Method: Observational, descriptive and retrospective study. 42 CLI patients admitted in our hospital from 2009 until 2018 with Fontaine III or IV treated by PTA in infrapopliteal arteries were analyzed, collecting demographic, clinical and surgical characteristics, additional procedures in Fontaine IV, hospital stay, postoperative complications, need of reintervention, limb preservation and mortality with one year follow-up after procedure. Results: 42 patients, average age 66 year-old (46-82), with significant comorbidities. Fontaine IV stage patients were 83.3%. In 16 cases more than one artery was intervened. No stent revascularization was performed. Complications occurred in 3 patients, 2 required major amputation and an urgent endovascular reintervention was required in another. Average hospital stay was 22 days with no post-operative mortality. One-year global mortality was 9.5 One-year follow-up in 35 patients shows that 77% preserved their limb. Conclusión: Percutaneous transluminal angioplasty procedure in this patients has a high rate of limb preservation in a one-year follow-up. There was no post-operative mortality.

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.

Tratamiento endovascular de trombosis de arteria poplítea mediante stent supera / Endovascular treatment of popliteal artery thrombosis with supera stent

La enfermedad arterial periférica es una patología muy prevalente en la sociedad, y se está desarrollando nuevas técnicas para tratarla mediante cirugía endovascular, mucho menos agresiva que las utilizadas hasta el momento. El sector Poplíteo por las fuerzas de elongación y torsión a las que está sometido, era hasta la aparición del stent Supera®, territorio de la cirugía abierta, pero gracias a las características de estos stents, nos permite realizar una cirugía menos invasiva en ese territorio. (AU)

The peripheral arterial disease is a very common pathology, and there are developments in new techniques to treat it by endovascular surgery, less aggressive than those used so far. The popliteal sector due to the elongation and torsion forces which is subjected, until the appear of Supera® stent, was only treated by open surgery, but thanks to this type of stent, allow us to treat that territory with less invasive surgeries

Endovascular revascularization of chronic total arterial occlusion of the lower limb using the SAFARI technique / Revascularização endovascular utilizando a técnica SAFARI em casos de oclusão arterial total do membro inferior

Abstract The SAFARI technique or Subintimal Arterial Flossing with Antegrade-Retrograde Intervention is an endovascular procedure that allows recanalization of Chronic Total Occlusive (CTO) lesions when conventional subintimal angioplasty is unsuccessful. Retrograde access is usually obtained through the popliteal, anterior tibial, dorsalis pedis artery, or posterior tibial arteries and may potentially provide more options for endovascular interventions in limb salvage. The case of an 81-year-old man with a history of uncontrolled hypertension, diabetes mellitus, and dyslipidemia is presented. He presented with a cutaneous ulcer on the right lower limb with torpid evolution and poor healing. The Doppler ultrasound and arteriographic study revealed a CTO lesion of the popliteal artery that was not a candidate for antegrade endovascular revascularization, but was successfully treated using the SAFARI technique. The patient had no perioperative complications, the wound showed better healing, and he was discharged with an indication of daily dressings and control by an external outpatient clinic.

Resumo A técnica SAFARI, ou Subintimal Arterial Flossing with Antegrade-Retrograde Intervention, é um procedimento endovascular que permite a recanalização de lesões por oclusão total crônica (OTC) em caso de fracasso da angioplastia subintimal convencional. O acesso retrógrado é geralmente obtido através da artéria poplítea, tibial anterior, pediosa ou tibial posterior e pode fornecer mais alternativas de intervenções endovasculares para o salvamento do membro. É apresentado o caso de um homem de 81 anos com histórico de hipertenção não controlada, diabetes melito e dislipidemia. Ele apresentava uma lesão ulcerativa cutânea no membro inferior direito com evolução tórpida e má cicatrização. O ultrassom Doppler e o estudo arteriográfico revelaram uma lesão por OTC na artéria poplítea. O paciente não era candidato a revascularização endovascular anterógrada; sendo assim, esta foi realizada com successo utilizando a técnica SAFARI. O paciente não apresentou complicações perioperatórias e recebeu alta com indicação de cuidados diários com a ferida e controle em um ambulatório externo. Além disso, a ferida apresentou melhor cicatrização.

Angioplastia transluminal percutánea de femoral superficial en paciente con oclusión de sectores fémoro-poplíteo e infra-poplíteo / Percutaneous Transluminal Angioplasty of the Superficial Femoral Artery in a Patient with Occlusion in the femoro-popliteal and infra-popliteal Sector

Introducción: La indicación más clara de revascularización en las extremidades inferiores lo constituye la presencia de lesiones isquémicas y el tratamiento de elección, siempre que sea posible, es el endovascular debido a su buena permeabilidad, baja morbilidad y mortalidad. Objetivo: Presentar un caso en el que se utilizó la angioplastia transluminal percutánea del sector fémoro-poplíteo. Presentación del caso: Se presenta un caso con diagnóstico de enfermedad arterial periférica en la extremidad inferior derecha. La angioplastia transluminal percutánea se utilizó para cicatrizar lesiones isquémicas aún en presencia de oclusiones no revascularizables de las arterias infra-poplíteas. El paciente presentaba al examen físico lesión isquémica en el primer dedo y patrón esteno-oclusivo fémoro-poplíteo. Se detectó disminución de los índices de presiones en poplítea y distales. En la arteriografía se apreciaron lesiones esteno-oclusivas en la femoral superficial y oclusión de las arterias infra-poplíteas. Se realizó angioplastia transluminal percutánea de la femoral superficial y el paciente recuperó pulso poplíteo con mejoría hemodinámica. Evolucionó satisfactoriamente y egresó con tratamiento médico. A los cinco meses de operado mantiene su pulso poplíteo presente y la lesión cicatrizada. Conclusión: La angioplastia del sector fémoro-poplíteo es beneficiosa para la cicatrización de la lesión isquémica aún en presencia de oclusiones infra-poplíteas no revascularizables(AU)

Introduction: The clearest indication for revascularization in lower limbs is the presence of ischemic lesions. The treatment of choice, whenever possible, is the endovascular one, due to its good permeability, as well as low morbidity and mortality. Objective: To present a case in which percutaneous transluminal angioplasty of the femoro-popliteal sector. Case presentation: A case is presented with a diagnosis of peripheral arterial disease in the right lower limb. The percutaneous transluminal angioplastywas used to heal ischemic lesions even in the presence of nonrevascularizable occlusions of the infra-popliteal arteries. On physical examination, the patient presented an ischemic lesion on the first finger and a femoro-popliteal steno-occlusive pattern. Decrease in pressure indices was detected in the popliteal and the distal ones. Arteriography showed steno-occlusive lesions in the superficial femoral and occlusion of the infra-popliteal arteries. Percutaneous transluminal angioplasty of the superficial femoral artery was performed and the patient recovered the popliteal pulse with hemodynamic improvement. The patient evolved satisfactorily and was discharged with medical treatment. Five months after surgery, the patient maintains popliteal pulse and the lesion has cicatrized. Conclusion: Angioplasty of the femoro-popliteal sector prove beneficial for the healing of the ischemic lesion even in the presence of nonrevascularizable infra-popliteal occlusions(AU)

Fístula coronaria a ventrículo derecho en paciente con ateroesclerosis sistémica / Coronary artery fistula to the right ventricle in a patient with systemic atherosclerosis

RESUMEN La ateroesclerosis es una enfermedad sistémica que afecta múltiples lechos vasculares. Después de períodos prolongados de progresión comienzan las manifestaciones clínicas, de forma aguda o crónica (infarto agudo de miocardio, angina estable, claudicación intermitente, enfermedad cerebrovascular, entre otras); por lo que puede cursar de manera subclínica en pacientes con enfermedad arterial coronaria. Lo interesante de esta forma de presentación es que dentro de una serie de casos con enfermedad multivaso, asociado a un índice tobillo-brazo (ITB) < 0,9, después de un síndrome coronario agudo, hemos encontrado, como hallazgo angiográfico, la presencia de una fístula coronaria a ventrículo derecho en un paciente con ITB muy bajo y clínica de claudicación intermitente. Esta fístula es la causa de los síntomas que interrumpieron la rehabilitación cardiovascular; es una enfermedad poco frecuente y causa de dolor torácico, que se informa solo de 0,3 a 0,8%, como hallazgo incidental en angiografías coronarias.

ABSTRACT Atherosclerosis is a systemic disease that affects a number of vascular beds. Clinical manifestations whether acute or chronic (acute myocardial infarction, stable angina, intermittent claudication, cerebrovascular disease, among others) start after long periods of progression; so it may present subclinically in patients with coronary artery disease. What is particularly interesting about this form of presentation is that within a series of cases with multivessel disease, associated with an ankle-brachial index (ABI)<0.9, after an acute coronary syndrome, we have identified, as an angiographic finding, the presence of a coronary artery fistula to the right ventricle in a patient with very low ABI and clinical intermittent claudication. This fistula led to the symptoms that hampered cardiovascular rehabilitation. It is an infrequent disease characterized by chest pain; with low reporting (0.3 to 0.8%), as an incidental finding in coronary angiographies.

COVID-19 diagnosis in a patient with critical limb ischemia: complications and clinical outcomes / Diagnóstico de COVID-19 em paciente com isquemia crítica do membro: complicações e desfechos clínicos

Abstract A 67-year-old male diabetic patient with systemic arterial hypertension was admitted to the emergency department with a necrotic ulcer in the left external malleolus and no palpable popliteal or pedal pulses. Arterial Duplex ultrasound identified femoropopliteal occlusion, with popliteal refilling below the knee and a patent peroneal artery. An endovascular procedure was performed, requiring retrograde access to the popliteal artery to re-establish blood flow and deploy a popliteal stent. Technical success was achieved and the patient underwent debridement of the wound. Two days later, about 48 hours after the operation, the patient began to exhibit respiratory symptoms, with coughing and dyspnea. He immediately underwent a chest CT that identified ground glass opacities, the crazy-paving pattern, and bilateral air bronchogram in the lungs. A reverse transcription - polymerase chain reaction (RT-PCR) test was positive for SARS-Cov-2. The patient was moved to an intensive care unit and put on mechanical ventilation. Both hydroxychloroquine and azithromycin were administered. Despite appropriate treatment, the patient died 4 days after he was diagnosed with COVID-19.

Resumo Paciente do sexo masculino, 67 anos, diabético, hipertenso, foi admitido no pronto-socorro com histórico de úlcera necrótica no maléolo externo esquerdo, sem pulsos poplíteos e distais palpáveis. A ultrassonografia Doppler arterial identificou oclusão femoropoplítea, com reenchimento da artéria poplítea infragenicular e perviedade da artéria fibular. Foi realizado procedimento endovascular, com necessidade de acesso retrógrado na artéria poplítea para restabelecer o fluxo sanguíneo e realizar implante de stent poplíteo. O sucesso técnico foi alcançado e, em seguida, o paciente foi submetido ao desbridamento da ferida. No segundo dia, cerca de 48 horas de pós-operatório, o paciente apresentou quadro respiratório com tosse e dispneia. Foi submetido a uma tomografia computadorizada do tórax, que identificou opacidades em vidro fosco e broncograma aéreo bilateralmente nos pulmões, com teste de reverse transcription - polymerase chain reaction (RT-PCR) positivo para SARS-Cov-2. O paciente foi transferido para uma unidade de terapia intensiva, necessitando de ventilação mecânica. Recebeu hidroxicloroquina e azitromicina. Apesar do tratamento em suporte intensivo, o paciente morreu 4 dias após o diagnóstico de COVID-19.

Arterialización del sistema venoso superficial para el salvamento de la extremidad en isquemia crítica / Arterialization of the superficial venous system for the salvage of a limb in critical ischemia

Introducción: La isquemia crítica es la más severa condición que afecta a los pacientes con enfermedad arterial periférica, con tendencia al empeoramiento progresivo y asociada con una alta tasa de amputación mayor, mortalidad y pobre calidad de vida. Objetivo: Exponer la arterialización del sistema venoso superficial como alternativa a la amputación mayor en pacientes con isquemia crítica sin opciones de revascularización Presentación del caso: Se presenta un caso con diagnóstico de isquemia crítica en el miembro inferior derecho, con alto riesgo de amputación mayor y sin posibilidades de revascularización. La paciente presentaba lesiones isquémicas en el pie y patrón oclusivo distal en el miembro inferior derecho, con un patrón hemodinámico calcificado. En la arteriografía se apreció oclusión de la arteria poplítea en su segunda porción sin restitución del flujo. Se le realizó arterialización de la vena safena mayor mediante tratamiento quirúrgico convencional desde la primera porción de la arteria poplítea. Conclusión: la arterialización del sistema venoso superficial permitió que la paciente salvara su extremidad y egresara sin una amputación mayor(AU)

Introduction: The critical ischemia is the most severe condition that affects patients with peripheral arterial illness, with tendency to progressive worsening and it is associated with a high rate of major amputation, mortality and poor quality of life. Objective: To present a case with critical limb ischemia without revascularization options and the arterialization of the superficial venous system as an alternative to major amputation. Case presentation: A case is presented with diagnostic of critical ischemia in the right lower limb with high risk of major amputation and without revascularization options. The patient presented ischemic lesions in the right foot and an occlusive distal pattern in the right lower limb with a calcified hemodynamic pattern. In the arteriography it was found an occlusion of the popliteal artery in its second portion without restitution of the flow. It was carried out the arterialization of the major safena vein by means of conventional surgical treatment from the first portion of the popliteal artery. Conclusions: The arterializations of the superficial venous system allowed the patient to save her limb and that discharged from the institution without a major amputation(AU)

Effectiveness of umbilical cord mesenchymal stem cells in patients with critical limb ischemia.

INTRODUCTION AND OBJECTIVE: Transplantation of umbilical cord mesenchymal stem cells (UC-MSCs) has been shown to be effective in treating critical limb ischemia (CLI). However, the mechanism of MSCs-mediated improvements, especially on the immune-inflammatory aspects of this disease, is still unknown. In this study, we investigated the changes in T-lymphocyte subpopulations and inflammatory mediators (such as IL-6, IL-10 and TNF-α) in PBMCs from CLI patients after UC-MSCs treatment and correlation between inflammatory mediators and EPCs. PATIENTS AND METHODS: 8 patients received UC-MSCs transplantation. Before the treatment, at 24h and 1 month thereafter, peripheral blood samples were collected from 8 patients and 8 healthy volunteers. Patients were evaluated for changes in IL-6, IL-10, TNF-α and levels of circulating EPCs. RESULTS: TNF-α and IL-6 serum levels increased at 24h (p=0.017, p=0.099) after treatment and then decreased at 1 month (p=0.031, p=0.072) compared with those before treatment. The percentages of CD3+T, CD3+CD4+T-lymphocytes and NK cells decreased significantly after UC-MSCs treatment (p=0.002, p=0.012 and p=0.029, respectively). TNF-α (r=-0.602, p=0.038) was shown to be inversely correlated with the number of circulating EPCs. CONCLUSIONS: This study demonstrates that UC-MSCs have anti-inflammatory and immunomodulation properties in CLI and suggests that UC-MSCs promote healing of non-healing wounds.

Factors associated with outcome of endovascular treatment of iliac occlusive disease: a single-center experience / Fatores associados com os desfechos clínicos do tratamento endovascular da doença oclusiva ilíaca: experiência de um único centro

Abstract Background Endovascular treatment (ET) of iliac occlusive disease (IOD) is well established in literature. Use of stents in IOD has achieved long-term limb salvage and patency rates similar to those of open surgery, with lower morbidity and mortality rates. Objectives To report the long-term outcomes, particularly limb salvage and patency rates, of ET for IOD and the factors associated with these outcomes. Methods This retrospective cohort study included patients with IOD who underwent iliac angioplasty (IA), between January 2009 and January 2015. Patients with critical limb ischemia or incapacitating claudication were included. Results In total, 48 IA procedures were performed in 46 patients, with an initial technical success rate of 95.83%. Failure occurred in two patients, who were excluded, leaving 44 patients and 46 IA. The primary patency, secondary patency, limb salvage, and survival rates at 1200 days were 88%, 95.3%, 86.3%, and 69.9%, respectively. Univariate and multivariate Cox regression revealed that the primary patency rate was significantly worse in patients with TASC type C/D than in patients with TASC type A/B (p = 0.044). Analysis of factors associated with major amputation using Cox regression showed that the rate of limb loss was greater in patients with TASC type C/D (p = 0.043). Male gender was associated with reduced survival (p = 0.011). Conclusions TASC type C/D was associated with a higher number of reinterventions and with worse limb loss and primary patency rates. Male gender was associated with a worse survival rate after ET of IOD.

Resumo Contexto O tratamento endovascular da doença oclusiva ilíaca (DOI) é bem estabelecido. O uso de stents nas angioplastias ilíacas (AI) alcançou estimativas de salvamento de membro e perviedade similares às de cirurgias abertas, porém com menor morbimortalidade. Objetivos Demonstrar os desfechos clínicos a longo prazo, principalmente as estimativas de salvamento de membro (ESM) e perviedade, do tratamento endovascular da DOI e os fatores associados. Método Estudo de coorte retrospectiva e consecutiva incluindo pacientes com DOI e isquemia crítica ou claudicação limitante submetidos a AI entre janeiro de 2009 a janeiro de 2015. Resultados Foram realizadas 48 AI em 46 pacientes, com uma taxa de sucesso técnico inicial de 95,83%. Ocorreu falha técnica em dois pacientes, os quais foram excluídos da análise, restando 44 pacientes e 46 AI. As estimativas de perviedade primária, perviedade secundária, ESM e sobrevida aos 1.200 dias foram de 88%, 95,3%, 86,3% e 69,9%, respectivamente. A regressão de Cox univariada e multivariada revelou que a perviedade primária foi pior em pacientes com classificação TASC C/D do que em pacientes TASC A/B (p = 0,044). Quando analisamos os fatores associados à amputação maior, verificou-se que lesões TASC tipo C/D (p = 0,043) apresentaram piores resultados. O sexo masculino foi associado com sobrevida reduzida (p = 0,011). Conclusões Classificação TASC tipo C/D foi associada a um maior número de reintervenções, maior perda de membro e piores estimativas de perviedade primária. O sexo masculino foi associado a uma pior sobrevida.

Acute upper limb ischemia, a rare presentation of giant cell arteritis.

Giant cell arteritis (GCA) is a systemic large vessel vasculitis, with extracranial arterial involvement described in 10-15% of cases, usually affecting the aorta and its branches. Patients with GCA are more likely to develop aortic aneurysms, but these are rarely present at the time of the diagnosis. We report the case of an 80-year-old Caucasian woman, who reported proximal muscle pain in the arms with morning stiffness of the shoulders for eight months. In the previous two months, she had developed worsening bilateral arm claudication, severe pain, cold extremities and digital necrosis. She had no palpable radial pulses and no measurable blood pressure. The patient had normochromic anemia, erythrocyte sedimentation rate of 120 mm/h, and a negative infectious and autoimmune workup. Computed tomography angiography revealed concentric wall thickening of the aorta extending to the aortic arch branches, particularly the subclavian and axillary arteries, which were severely stenotic, with areas of bilateral occlusion and an aneurysm of the ascending aorta (47 mm). Despite corticosteroid therapy there was progression to acute critical ischemia. She accordingly underwent surgical revascularization using a bilateral carotid-humeral bypass. After surgery, corticosteroid therapy was maintained and at six-month follow-up she was clinically stable with reduced inflammatory markers. GCA, usually a chronic benign vasculitis, presented exceptionally in this case as acute critical upper limb ischemia, resulting from a massive inflammatory process of the subclavian and axillary arteries, treated with salvage surgical revascularization.

Predictors of medium-term patency in percutaneous endovascular therapy of femoro-popliteal lesions.

BACKGROUND: The objective is to study the medium-term results of angioplasty and stenting in the femoro-popliteal sector in patients with critical limb ischemia (CLI), and identify angiographic predictive factors of primary patency. PATIENTS AND METHODS: Retrospective review of 98 patients with critical ischemia and angiographic lesions characterized as TASC A=13 (14%), B=38 (40%), C=24 (25%) or D=20 (21%). A total of 106 angioplasties and primary self-expanding stents (mean length of stent coverage of 19cm) were performed between January 2006 and January 2011. RESULTS: The immediate results of patency, limb salvage and survival were 95, 96 and 96%, respectively. Primary patency at 1 and 2 years was 54 and 38%, respectively. Twenty-seven cases (25%) required endovascular iterative procedures, providing an assisted patency at 1 and 2 years of 72 and 60%, and a secondary patency of 80 and 67%. A lower primary patency was observed (log rank) when stent length was >20cm (P<.001), popliteal artery was invloved (P=.004), and in TASC C and D lesions (P=.04). In multivariate analysis (Cox), only stent length>20cm was an independent negative predictor for primary patency (HR=5.7, P<.001). The limb salvage at 1 and 2 years was 83 and 81%, respectively. CONCLUSIONS: Angioplasty with stent in the femoro-popliteal sector is a safe technique, but with significantly lower permeability results in injuries that require stent coverage of more than 20cm. In these cases, vein bypass surgery should be the procedure of choice.

Caracterización de los pacientes ingresados por isquemia crítica de los miembros inferiores / Characterization of hospitalized patients with critical ischemia of the lower limbs

Objetivo: caracterizar a los pacientes ingresados con el diagnóstico de isquemia crítica de los miembros inferiores y la actitud terapéutica en el salvataje de la extremidad.Métodos: se analizaron los expedientes clínicos, sin distinción de sexos, de 65 pacientes no diabéticos. Se extrajeron los siguientes datos: factores de riesgo, sectores arteriales afectados, diagnóstico clínico al ingreso, procederes quirúrgicos realizados. Se calculó la tasa de salvación de extremidades.Resultados: se encontró que el tabaquismo fue el único factor de riesgo que estuvo presente en todos los pacientes según sectores arteriales afectados. Los patrones oclusivos más frecuentes fueron el aortoilíaco en 13 (20 por ciento) pacientes, el femoropoplíteo en 31 (47,7 por ciento) y el distal en 21 (32,3 por ciento). Se observó que 42 (64,6 por ciento) enfermos ingresaron por lesiones isquémicas y 23 (35,4 por ciento) por dolor de reposo. Los procederes más realizados fueron las amputaciones primarias, las derivaciones con prótesis y con igual frecuencia las endarterectomías y la simpatectomía lumbar. La primera en los sectores femoropoplíteo y distal, la segunda en los sectores aortoilíaco y femoropoplíteo, la tercera en el aortoilíaco y la cuarta en el distal La mejor tasa de salvación de extremidades se obtuvo en el sector aortoilíaco. Conclusiones: el estado avanzado y grave de las lesiones hacen pensar en la necesidad de un diagnóstico precoz para evitar la amputación y así elevar más la tasa global de salvación de extremidades(AU)

Objective: to characterize the hospitalized patients with a diagnosis of critical lower limb ischemic, and the therapeutic procedure to save the extremity. Methods: the medical histories of 65 non- diabetic patients of both sexes were analyzed. The following information was drawn: risk factors, affected arterial sectors, clinical diagnosis on admission, and surgical procedures performed. The rate of preservation of limbs was estimated. Results: it was found that smoking was the only risk factor present in all the affected arterial sectors. The most frequent occlusive patterns were the aortic-iliac (20,0 percent), the femoral-popliteal (47.7 percent) and the distal (32.3 percent). It was observed that 42 (64.6 percent) patients were hospitalized due to ischemic lesions and 23 due to pain at rest. injuries ischemic and 35,4 percent for rest pain. The most performed procedures were primary amputations (40,0 percent), the derivations with prosthesis (16.9 percent), and endarterectomy and lumbar sympatectomy with equal frequency (12.3 percent). The first procedure was performed in the femoral-popliteal (38.7 percent) and the distal (52.4 percent)sectors; the second one in the aortic-iliac sectors (30.7 percent) and the femoral-popliteal (22.6 percent), the third one in the aortic-iliac sector (23.1 percent) and the fourth one in the distal (33.3 percent). The best rate of extremity preservation was seen in the aortic-iliac sector. Conclusions: The serious advanced state of lesions indicates the need of early diagnosis in order to avoid amputation and raise the overall rate of extremity preservation(AU)

Angioplastia transluminal percutânea sem implante primário de stents para salvamento de membros / Percutaneous transluminal angioplasty without primary implant of stents for saving members. Sao Paulo

Introdução: A isquemia crítica de membros (ICM) é a forma mais grave de manifestação da insuficiência arterial periférica crônica (IAPC), promovendo alta taxa de morbi-mortalidade e amputação. A terapia endovascular consolidou-se no arsenal terapêutico da IAPC, configurando a primeira opção de tratamento aos pacientes portadores de ICM. Objetivo: Avaliar o resultado da angioplastia transluminal percutânea (ATP) sem implante primário de stents quanto às taxas de salvamento de membros e complicações periprocedimento, juntamente com as taxas de perviedade assistida pelo Doppler colorido das lesões alvo. Materiais e métodos: Pacientes portadores de ICM foram submetidos a ATP sem implante primário de stents no período de março de 2012 a junho de 2013. Foram incluídos os portadores de alterações classificadas nas categorias 4 e 5 de Rutherford. Foram excluídos os pacientes em que não foi obtido sucesso técnico, totalizando 51 procedimentos. A ICM foi distribuída em território e de acordo com a classificação TASC, sendo 29% aortoilíaco, 51% femoropoplíteo e 20% infrapoplíteo. Os segmentos arteriais tratados foram acompanhados por mapeamento duplex colorido fornecendo taxas de perviedade assistida. Resultados: O estudo apresentou taxa de complicação/óbito de 12% com taxa de salvamento de membros de 83,1%. As taxas cumulativas de perviedade primária, primária assistida e secundária em 12 meses foram respectivamente: 50,1%, 80,2% e 93,8%. Pacientes apresentavam mais de uma comorbidade associada, prevalecendo a HAS em 76%. Discussão: As taxas de salvamento de membros foram elevadas associadas à perviedade primária assistida e secundária. As baixas taxas de perviedade primária não influenciaram no salvamento de membro. Conclusão: ATP sem implante primário de stents mostrouse segura e efetiva no tratamento da ICM, com altas taxas de sucesso clínico, podendo ser a primeira opção de tratamento. Como ferramenta aliada o Doppler pode aumentar as taxas de perviedade final.

Tratamiento endovascular de las arterias distales del miembro inferior / Endovascular treatment of distal lower limb arteries / Tratamento endovascular das artérias distais do membro inferior

La angioplastía es un procedimiento que se ha introducido en el tratamiento de las lesiones oclusivas de los miembros inferiores con resultados prometedores. No obstante, son importantes los nuevos aportes de datos sobre los resultados obtenidos, teniendo en cuenta la falta de homogeneidad de los pacientes tratados afectados por diferentes procesos obstructivos arteriales, tratados en diferentes situaciones clínicas y con una muy variada extensión de las lesiones. Se realiza un análisis de 239 casos incluidos en un estudio prospectivo con el objetivo de analizar los resultados en relación a los diversos factores que afectan a los pacientes. Se analizan los resultados y se valoran los mismos.

A angioplastia é um procedimento que foi introduzido no tratamento das lesões oclusivas dos membros inferiores com resultados prometedores. Entretanto, são importantes as novas contribuições de dados sobre os resultados obtidos, levando em consideração a falta de homogeneidade dos pacientes tratados afetados por diferentes processos obstrutivos arteriais, tratados em diferentes situações clínicas e com uma muito variada extensão das lesões. Realiza-se uma análise de 239 casos incluídos em um estudo prospectivo com o objetivo de analisar os resultados com relação aos diversos fatores que afetam os pacientes. Analisam-se os resultados e se valorizam os mesmos.

Angioplasty is a procedure that has been introduced with promising results in the treatment of occlusive lesions of the lower limbs. However, it is necessary further input of data on the results obtained taking into account the lack of homogeneity of patients suffering from obstructive arterial different processes, treated in different clinical situations and with a very wide extent of the injury. An analysis of 239 cases in a prospective study to analyze the results in relation to the various factors that affect patients. The results are analyzed and valued the same.