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Background Buerger disease, also known as Winiwarter–Buerger disease or thromboangiitis obliterans (TAO), is a non-specific inflammation of small- and medium-sized arteries with thrombus obliteration and without atherosclerotic changes. Patients with TAO can develop chronic limb-threatening ischaemia (CLTI) and are at risk of limb amputation despite smoking cessation and exercise therapy recommendations. Case summary A 72-year-old Japanese man presented with painful discolouration of toes and renal impairment. He was diagnosed with Rutherford classification Stage 6 CLTI with immunoglobulin A nephropathy. He refused limb amputation. Clinical symptoms reduced after treatment with low-intensity pulsed ultrasound (LIPUS). LIPUS is a non-invasive option to alleviate peripheral arterial disease symptoms. Despite the initiation of conventional therapy measures, there was a worsening of the limb condition. The non-invasive investigational treatment option of LIPUS was initiated after the poor clinical outcomes of the conventional therapy measures. The patient's symptoms in the bilateral lower limbs, ulcers, and the blue-coloured toes gradually lessened. After 1 year of treatment with LIPUS, he had achieved better walking independence with improved quality of life. Discussion Low-intensity pulsed ultrasound is a non-invasive option for therapeutic angiogenesis with the potential to improve ischaemic limb conditions in patients with peripheral arterial disease and to avoid major amputation procedures. [ABSTRACT FROM AUTHOR]

We describe a unique presentation of acute lower limb ischaemia due to metastatic seminoma in a middle-aged man with a large retroperitoneal mass. The patient underwent vascular bypass surgery of the right lower limb, completed chemotherapy, and had a right scrotal orchiectomy. The patient had pre-existing vascular risk factors including peripheral vascular disease and smoking. To our knowledge this is the first published case in the literature that has described a large retroperitoneal seminoma compressing the abdominal aorta resulting in acute lower limb ischaemia.

This study aimed to evaluate the safety and effectiveness of the Penumbra Indigo percutaneous aspiration thrombectomy (PAT) system in the clinical presentation of iliac limb occlusion (ILO) after endovascular aortic repair (EVAR). A r etrospective, observational, multicentre study conducted in eight Italian vascular centres. Consecutive patients presenting with ILO after EVAR were eligible. To assess vessel revascularisation, Thrombo-aspiration In Peripheral Ischaemia (TIPI) classification (score 0–3) was used at presentation (t1), after PAT (t2), and after adjunctive procedures (t3). Successful revascularisation was considered TIPI 2–3 (near complete or complete). Primary intra-operative outcomes were technical success (TS) of Indigo PAT and combined TS of PAT associated with adjunctive procedures when needed. Primary follow up outcomes were safety and effectiveness at one, six, and 12 months. From September 2019 to December 2021, there were 48 ILO and 17 patients (35%) [median age 75 years, IQR 71, 83 years; male, 14 (82%); urgent, 8 (47%)] were treated and enrolled. The median time after primary EVAR was 24 months (IQR 0, 42 months). The median clot age from ILO diagnosis to PAT was three days (IQR 1, 12 days). Ten patients (59%) presented with limb threatening ischaemia. At t1, TIPI 0 and 1 was present in 13 (76%) and four (24%) cases, respectively. At t2, primary TS (TIPI 2–3) was achieved in 14 cases (82%) after Indigo PAT (p <.001). Fifteen patients (88%) required adjunctive procedures (14 re-linings, one surgical patch angioplasty). At t3, combined TS was achieved in 16 cases (94%). Intra-operative complication included one (6%) distal embolisation, treated successfully. The 30 day mortality was one case (6%) due to pneumonia. At one, six, and 12 months, clinical success was 100% without ILO recurrence. The median follow up was 23 months (IQR 11, 41 months): at 18 months, survival and freedom from re-intervention were 91 ± 8% and 90 ± 9%, respectively. This study reports for the first time the efficacy and safety of Penumbra Indigo PAT for ILO after EVAR, with promising technical and clinical success up to one year. [ABSTRACT FROM AUTHOR]

The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock is rising. Acute limb ischaemia remains one of the main complications after ECMO initiation. We analysed 104 patients from our databank from January 2015 to December 2021 who were supported with mobile ECMO therapy. We aimed to identify the impact of acute limb ischaemia on short-term outcomes in patients placed on ECMO in our institution. The main indication for ECMO therapy was left ventricular (LV) failure with cardiogenic shock (57.7%). Diameters of arterial cannulas (p = 0.365) showed no significant differences between both groups. Furthermore, concomitant intra-aortic balloon pump (IABP, p = 0.589) and Impella (p = 0.385) implantation did not differ significantly between both groups. Distal leg perfusion was established in approximately 70% of patients in two groups with no statistically significant difference (p = 0.960). Acute limb ischaemia occurred in 18.3% of cases (n = 19). In-hospital mortality was not significantly different (p = 0.799) in both groups. However, the bleeding rate was significantly higher (p = 0.005) in the limb ischaemia group compared to the no-limb ischaemia group. Therefore, early diagnosis and prevention of acute limb ischaemia might decrease haemorrhage complications in patients during ECMO therapy. [ABSTRACT FROM AUTHOR]

Prompt diagnosis and intervention are essential for acute limb ischaemia after trauma. Guidelines for diagnosis are changing with new evidence. Pulse oximetry may be a useful adjunct. We aim to assess the value of pulse oximetry and other common tests for diagnosing vascular injury. Electronic medical records of patients with limb injuries were identified. Patient demographics, the mechanism of injury, comorbidities, the results of diagnostic tests or examinations, and the end outcome were extracted. Receiver Operator Characteristics (ROC) curves were used to calculate cut-offs with optimum sensitivity and specificity for pulse oximetry. Performance characteristics to predict vascular injury for all documented tests were calculated and compared. SpO2 values were significantly different in the group with and without vascular disruption (p = 0.034). Using a cut-off of 96% calculated from ROC curve analysis, SpO 2 had a sensitivity of 78% and a specificity of 90%. For the other techniques, abnormal pulse oximetry waveform, absent distal pulses, and capillary refill over 2 s were significantly different between the two groups. Abnormal pulse oximetry waveform had the highest specificity (100%) while SpO2 was the most sensitive (78%). We suggest that pulse oximetry is a useful adjunct for patients with limb trauma, an abnormal waveform or SpO2 value below 96% suggests vascular disruption is present. Capillary refill over 2 s and absent distal pulses can also be used; if either are positive, this suggests vascular disruption. No test or examination was shown to be able to exclude vascular injury. [ABSTRACT FROM AUTHOR]

COVID-19 infection or vaccination is rarely associated with arterial occlusive disease of the extremities. The surgical department of a hospital in Johor, Malaysia, recorded a significant increase in the number of COVID-19-related acute limb ischaemia when the rates of COVID-19 were high both locally and internationally. The clinical presentation and management of acute limb ischaemia associated with COVID-19 infection or vaccination are largely underreported in Johor. Herein, we report a case series of 12 patients managed with strategies ranging from purely anticoagulation to catheter-directed thrombolysis and surgical embolectomy. This case series describes the clinical presentation, risk profiles, treatment approaches and limb outcomes of the patients. The amputation rate was high in view of unfavourable factors, including delayed presentation, high-risk factors and severe COVID-19. Three cases of potential COVID-19 vaccine-related acute limb ischaemia were included. COVID-19-related acute limb ischaemia can be minimised with heightened alert, preemptive optimisation with proper hydration and consideration for early prophylactic anticoagulation in high-risk cases.

The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock is rising. Acute limb ischaemia remains one of the main complications after ECMO initiation. We analysed 104 patients from our databank from January 2015 to December 2021 who were supported with mobile ECMO therapy. We aimed to identify the impact of acute limb ischaemia on short-term outcomes in patients placed on ECMO in our institution. The main indication for ECMO therapy was left ventricular (LV) failure with cardiogenic shock (57.7%). Diameters of arterial cannulas (p = 0.365) showed no significant differences between both groups. Furthermore, concomitant intra-aortic balloon pump (IABP, p = 0.589) and Impella (p = 0.385) implantation did not differ significantly between both groups. Distal leg perfusion was established in approximately 70% of patients in two groups with no statistically significant difference (p = 0.960). Acute limb ischaemia occurred in 18.3% of cases (n = 19). In-hospital mortality was not significantly different (p = 0.799) in both groups. However, the bleeding rate was significantly higher (p = 0.005) in the limb ischaemia group compared to the no-limb ischaemia group. Therefore, early diagnosis and prevention of acute limb ischaemia might decrease haemorrhage complications in patients during ECMO therapy.

Objective: Local intramuscular transplantation of granulocyte colony-stimulating factor (G-CSF)-mobilised peripheral blood mononuclear cells (PB-MNC) has been shown to be effective for treating patients with no-option critical limb ischaemia (CLI) who are not considered suitable to undergo surgical bypass or percutaneous transluminal angioplasty. The aim of this study was to investigate the effectiveness and safety of PB-MNCs as a treatment for no-option CLI patients. Method: This prospective cohort study was conducted between April 2013 and December 2017. Patients with no-option CLI were treated with G-CSF 5-10 µg/kg/day for 3 days. PB-MNCs (7.1±2.2x1010) with CD34+ cells (2.1±1.2x108) were collected by blood cell separator and then injected into the calf or thigh of ischaemic limbs. Ankle--brachial index, toe--brachial index and transcutaneous oxygen tension were recorded at 1 and 3 months after injection. The amputation rate and the wound healing rate were also recorded. Results: Eight patients took part in the study. Two patients experienced rest pain relief 1 month after PB-MNC therapy. Five patients had healed ulcer at 6 months after PB-MNC therapy. Limb ischaemia did not improve after PB-MNC therapy in one patient. Below-knee amputation was performed in that patient due to extension of gangrene. Two patients required reinjection of PB-MNCs because of recurrence of ischaemic ulcer. The limb salvage rate after 1 year was 87.5%. Conclusion: Local intramuscular transplantation of G-CSF-mobilised PB-MNCs might be a safe and effective treatment for no-option CLI patients. Declaration of interest: This study was supported by a grant from the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (grant no. R015533013). All authors declare no personal or professional conflicts of interest, and no financial support from the companies that produce and/or distribute the drugs, devices or materials described in this report. [ABSTRACT FROM AUTHOR]

The aim was to evaluate the short term safety and effectiveness of the Penumbra/Indigo aspiration thrombectomy Systems (Penumbra Inc.) in patients with acute lower limb ischaemia. (ALLI). Recently, endovascular vacuum assisted thrombectomy devices, similar to those used in the management of acute ischaemic stroke, have become available for peripheral arteries, but data are still scarce. To assess vessel patency, a modified Thrombolysis in Myocardial Infarction (TIMI) classification, called TIPI (Thrombo-aspiration In Peripheral Ischaemia), is proposed. The TIPI flow is assessed at presentation, immediately after treatment with the study device, and after all adjuvant procedures. The primary outcome is the technical success of the thrombo-aspiration with the investigative system, defined as near complete or complete revascularisation TIPI 2 – 3. Safety and clinical success rate were collected at one month. One hundred and fifty patients were enrolled. The mean age was 72.4 years and 73.3% were male. Rutherford grade on enrolment was I in 16%, IIa in 40.7%, and IIb in 43.3% with a mean ankle brachial index of 0.19. Primary technical success (TIPI 2 – 3 flow) was achieved in 88.7% of patients. Adjunctive procedures included angioplasty/stenting of chronic atherosclerotic lesions (n = 39), thrombolysis (n = 31), covered stenting (n = 15), and supplementary Fogarty embolectomy (n = 6). After all interventions, assisted primary technical success was 95.3% (TIPI 2 – 3 in 143/150). No systemic bleeding complications or device related serious adverse events were reported. At one month follow up, one death, and one below the knee amputation were recorded. Primary patency was 92% (138/150), and the re-intervention rate was 7.33%, resulting in an assisted primary and secondary patency of 94% and 99.33%, respectively. Results from the INDIAN registry reveal that mechanical thrombectomy using the Indigo system is safe and effective for revascularisation of ALLI as a primary therapy. [ABSTRACT FROM AUTHOR]

During the most aggressive phase of the COVID-19 outbreak in Italy, the Regional Authority of Lombardy identified a number of hospitals, named Hubs, chosen to serve the whole region for highly specialised cases, including vascular surgery. This study reports the experience of the four Hubs for Vascular Surgery in Lombardy and provides a comparison of in hospital mortality and major adverse events (MAEs) according to COVID-19 testing. Data from all patients who were referred to the Vascular Surgery Department of Hubs from 9 March to 28 April 2020 were collected prospectively and analysed. A positive COVID-19 polymerase chain reaction swab test, or symptoms (fever > 37.5 °C, upper respiratory tract symptoms, chest pain, and contact/travel history) associated with interstitial pneumonia on chest computed tomography scan were considered diagnostic of COVID-19 disease. Patient characteristics, operative variables, and in hospital outcomes were compared according to COVID-19 testing. A multivariable model was used to identify independent predictors of in hospital death and MAEs. Among 305 included patients, 64 (21%) tested positive for COVID-19 (COVID group) and 241 (79%) did not (non-COVID group). COVID patients presented more frequently with acute limb ischaemia than non-COVID patients (64% vs. 23%; p <.001) and had a significantly higher in hospital mortality (25% vs. 6%; p <.001). Clinical success, MAEs, re-interventions, and pulmonary and renal complications were significantly worse in COVID patients. Independent risk factors for in hospital death were COVID (OR 4.1), medical treatment (OR 7.2), and emergency setting (OR 13.6). COVID (OR 3.4), obesity class V (OR 13.5), and emergency setting (OR 4.0) were independent risk factors for development of MAEs. During the COVID-19 pandemic in Lombardy, acute limb ischaemia was the most frequent vascular disease requiring surgical treatment. COVID-19 was associated with a fourfold increased risk of death and a threefold increased risk of major adverse events. [ABSTRACT FROM AUTHOR]

Polyarteritis nodosa (PAN) is a rare form of vasculitis which involves medium and small sized arteries. It can involve any system of the body, but lungs are typically spared. PAN typically presents with non-specific symptoms, such as fever, weight loss and myalgias, and symptoms related to the system involved. Negative serum ANCA helps in differentiating it from other similarly presenting vasculitis and definitive diagnosis is made on histopathology. Limb ischaemia is a rare presentation as well as a rare complication of PAN. We present the case of a 28-year-old female who presented with severe lower limb ischaemia and intermittent leg claudication as initial symptoms which led to initial diagnosis of critical limb ischaemia. Later in the course of the illness she developed gastrointestinal symptoms and weight loss. She was diagnosed as having PAN based on laboratory results and histopathological evidence. Intravenous steroids halted the progress of the disease, but the patient required transmetatarsal amputation of the foot to remove dead tissue. Vasculitis like PAN, although much rarer than atherosclerotic peripheral vascular disease (PVD), should be considered as a differential diagnosis in cases of limb ischaemia in which there is lack of risk factors for PVD. [ABSTRACT FROM AUTHOR]

Objective: Adipose‐derived mesenchymal stem cells (ADSCs) offer great promise as cell therapy for ischaemic diseases. Due to their poor survival in the ischaemic environment, the therapeutic efficacy of ADSCs is still relatively low. Interleukin‐11 (IL‐11) has been shown to play a key role in promoting cell proliferation and protecting cells from oxidative stress injury. The aim of this study was to determine whether IL‐11 could improve therapeutic efficacy of ADSCs in ischaemic diseases. Methods and Results: ADSCs were prepared from inguinal subcutaneous adipose tissue and exposed to hypoxic environment. The protein expression of IL‐11 was decreased after hypoxic treatment. In addition, ADSCs viability was increased after IL‐11 treatment under hypoxia. Moreover, IL‐11 enhanced ADSCs viability in a dose‐dependent manner under normoxia. Importantly, IL‐11 promoted ADSCs proliferation and migration and protected ADSCs against hydrogen peroxide‐induced cellular death. Notably, IL‐11 enhanced ADSCs proliferation and migration, also promoted cell survival and apoptosis resistance by STAT3 signalling. In vivo, mice were subjected to limb ischaemia and treated with IL‐11 overexpression ADSCs and control ADSCs. IL‐11 overexpression ADSCs improved perfusion recovery in the ischaemic muscles. Conclusions: We provide the evidence that IL‐11 promoted ADSCs proliferation, stimulated ADSCs migration and attenuated ADSCs apoptosis by activation of STAT3 signalling. These results suggest that IL‐11 facilitated ADSCs engraftment in ischaemic tissue, thereby enhanced ADSCs therapeutic efficacy. [ABSTRACT FROM AUTHOR]

Objective: Diabetes mellitus is a significant risk factor for peripheral artery disease. Diabetes mellitus induces chronic states of oxidative stress and vascular inflammation that increase neutrophil activation and release of myeloperoxidase. The goal of this study is to determine whether inhibiting myeloperoxidase reduces oxidative stress and neutrophil infiltration, increases vascularization, and improves blood flow in a diabetic murine model of hindlimb ischaemia. Methods: Leptin receptor–deficient (db/db) mice were subjected to hindlimb ischaemia. Ischaemic mice were treated with N -acetyl-lysyltyrosylcysteine-amide (KYC) to inhibit myeloperoxidase. After ligating the femoral artery, effects of treatments were determined with respect to hindlimb blood flow, neutrophil infiltration, oxidative damage, and the capability of hindlimb extracellular matrix to support human endothelial cell proliferation and migration. Results: KYC treatment improved hindlimb blood flow at 7 and 14 days in db/db mice; decreased the formation of advanced glycation end products, 4-hydroxynonenal, and 3-chlorotyrosine; reduced neutrophil infiltration into the hindlimbs; and improved the ability of hindlimb extracellular matrix from db/db mice to support endothelial cell proliferation and migration. Conclusion: These results demonstrate that inhibiting myeloperoxidase reduces oxidative stress in ischaemic hindlimbs of db/db mice, which improves blood flow and reduces neutrophil infiltration such that hindlimb extracellular matrix from db/db mice supports endothelial cell proliferation and migration. [ABSTRACT FROM AUTHOR]

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Endothelial progenitor cells (EPCs) are a group of heterogeneous cells in bone marrow (BM) and blood. Ischaemia increases reactive oxygen species (ROS) production that regulates EPC number and function. The present study was conducted to determine if ischaemia‐induced ROS differentially regulated individual EPC subpopulations using a mouse model concomitantly overexpressing superoxide dismutase (SOD)1, SOD3 and glutathione peroxidase. Limb ischaemia was induced by femoral artery ligation in male transgenic mice with their wild‐type littermate as control. BM and blood cells were collected for EPCs analysis and mononuclear cell intracellular ROS production, apoptosis and proliferation at baseline, day 3 and day 21 after ischaemia. Cells positive for c‐Kit+/CD31+ or Sca‐1+/Flk‐1+ or CD34+/CD133+ or CD34+/Flk‐1+ were identified as EPCs. ischaemia significantly increased ROS production and cell apoptosis and decreased proliferation of circulating and BM mononuclear cells and increased BM and circulating EPCs levels. Overexpression of triple antioxidant enzymes effectively prevented ischaemia‐induced ROS production with significantly decreased cell apoptosis and preserved proliferation and significantly increased circulating EPCs level without significant changes in BM EPC populations, associated with enhanced recovery of blood flow and function of the ischemic limb. These data suggested that ischaemia‐induced ROS was differentially involved in the regulation of circulating EPC population. [ABSTRACT FROM AUTHOR]

Objective/background Lower limb peripheral arterial disease (PAD) is becoming increasingly common. Lower limb perfusion, as determined by the ankle brachial pressure index (ABPI), is a recognised predictor of overall mortality. The increasing role of non-invasive imaging in patient assessment may aid in the ability to predict poor patient outcomes. Methods This study included all patients undergoing a lower limb arterial duplex over a period of 20 months. The site and burden of atherosclerosis within the lower limb was determined using the well validated Bollinger score. Patient demographic data were also collated. The primary outcome measure was all cause mortality. Results A total of 678 patients were included (median age 74 years). The overall median follow up period was 69.9 months. Of these, 307 patients reached the primary end point, which was death. Independent predictors of all cause mortality included total Bollinger score (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.05–1.18 [ p <.001]; OR per 10 points), femoropopliteal Bollinger score (OR 1.34, 95% CI 1.11–1.08 [ p =.05]; OR per 10 points), and crural Bollinger score (OR 1.03, 95% CI 1.01–1.03 [ p =.03]). There was also a significant association between mortality and age, a prior history of ischaemic heart disease, a history of congestive cardiac failure and chronic renal failure (chronic kidney disease ≥ 3). Statin and antiplatelet therapy were protective. Conclusion This contemporary study confirms poor long-term outcomes still exist in patients with PAD. The site and severity of lower limb atherosclerosis are independent predictors of long-term mortality. [ABSTRACT FROM AUTHOR]

The presence of distal pulses can be misleading and the presence of good vascularity to the affected part may be unrelated to the possibility of a vascular injury in orthopaedic trauma to the affected part. We report a case of Grade II open fracture of Proximal Tibia with Posterior Tibial Artery (PTA) tear. The case being presented came with an intact PTA pulsations clinically and with good vascularity to the lower limb, with no difference in the pulse rate between radial and posterior tibial pulse rate and no underlying bruits. The underlying PTA tear was found only incidentally on operating when the patient was taken up for open reduction with internal fixation with proximal tibial locking plate surgical procedure and the fracture site was opened. Arterial injuries following trauma may be missed without liberal use of arterial Arteriograms and Doppler study, unless looked for with a high degree of suspicion. If the arterial tear is identified early, patient and his limb can be saved without much morbidity to the patient, though diagnosing the injury is the hard part. Presence of intact and good peripheral pulses is not a sole criteria to rule out underlying vascular injury following orthopaedic trauma.

The application of a tourniquet is a routine adjunct to current orthopaedic surgical practice. It is commonplace for both elective and trauma surgery. This review article seeks to explore the issues surrounding tourniquet and current best practice. The technological evolution in the application of a tourniquet to produce a bloodless field has remained relatively unchanged compared to other more complex advances in modern surgical practice. Despite a tourniquet's relative simplicity, considerable controversy surrounds its exact application; the surgeon constantly seeks a balance between the inevitable morbidity associated with its use versus the advantages conferred by such a device. To trace the history of the tourniquet is of interest and provides a backdrop to understanding the current controversies associated with its use as well as predicting where the next possible evolutions might take place. The tourniquet is often taken for granted, but there is a considerable body of work surrounding its use and safe application. Correct application, training of staff and appropriate use on an individual basis are essential to maximize safety and benefit. [ABSTRACT FROM AUTHOR]

Acute (ALI) and chronic limb ischaemic (CLI) make up a major part of the workload of vascular surgeons and carry considerable morbidity and mortality. Peripheral artery disease (PAD) is the major cause of these conditions. Diagnosis of these conditions involves proper use of imaging including duplex ultrasound, computed tomography angiography (CTA), magnetic resonance angiography (MRA), as well as invasive techniques like digital subtraction angiography (DSA). Management ranges from conservative techniques, the mainstay of management in intermittent claudication (IC), with medical optimization, through to endovascular and open revascularization techniques in CLI and ALI. Finally where no revascularization options exist, primary amputation or palliation must be considered. [ABSTRACT FROM AUTHOR]

The presence of distal pulses can be misleading and the presence of good vascularity to the affected part may be unrelated to the possibility of a vascular injury in orthopaedic trauma to the affected part. We report a case of Grade II open fracture of Proximal Tibia with Posterior Tibial Artery (PTA) tear. The case being presented came with an intact PTA pulsations clinically and with good vascularity to the lower limb, with no difference in the pulse rate between radial and posterior tibial pulse rate and no underlying bruits. The underlying PTA tear was found only incidentally on operating when the patient was taken up for open reduction with internal fixation with proximal tibial locking plate surgical procedure and the fracture site was opened. Arterial injuries following trauma may be missed without liberal use of arterial Arteriograms and Doppler study, unless looked for with a high degree of suspicion. If the arterial tear is identified early, patient and his limb can be saved without much morbidity to the patient, though diagnosing the injury is the hard part. Presence of intact and good peripheral pulses is not a sole criteria to rule out underlying vascular injury following orthopaedic trauma. [ABSTRACT FROM AUTHOR]

Persistent sciatic artery is a rare embryological anomaly. The authors report the clinical case of a 81-year-old man presenting with a right lower limb ischaemia and a pulsatile mass in the buttock. Computed tomographic angiography demonstrated a complete and unilateral persistent sciatic artery, with an aneurysmal degeneration on its, proximal third. During the pre-operative workup, spontaneous aneurismal occlusion occurred, worsening the condition to a critical ischaemia. The patient underwent, successfully, a distal femoro-popliteal bypass. Review of the literature confirms the rarity of this anomaly, which is frequently associated to degenerative changes. Surgical repair is prompt recommended to prevent complications.A persistência da artéria ciática é uma anomalia embriológica rara. Os autores relatam o caso clínico de um homem de 81 anos de idade, que se apresentou com sinais de isquemia do membro inferior direito associado a uma massa pulsátil na região glútea. Foi realizada uma angiografia por TC que mostrou a presença de uma artéria ciática completa e unilateral no membro inferior direito, com degenerescência aneurismática no seu terço proximal. Durante a avaliação pré-operatória, o doente desenvolveu um quadro de isquemia crítica por oclusão espontânea do aneurisma da artéria ciática, pelo que foi submetido com sucesso a um bypass femoro-poplíteo infra-genicular. A revisão da literatura confirma a raridade desta entidade, assim como a tendência da artéria ciática para alterações degenerativas precoces. A correção cirúrgica deve ser expedita para prevenir complicações decorrentes das alterações degenerativas.

Objective: This paper evaluates a prototype flat-panel volume CT (fpVCT) for dynamic in vivo imaging in a variety of neurovascular and lower limb applications. Methods: Dynamic CTA was performed on 12 patients (neuro = 8, lower limb = 4) using an fpVCT with 120 kVp, 50 mA, rotation time varying from 8 to 19 s, and field of view of 25 × 25 × 18 cm. Four-dimensional data sets (i.e. 3D images over time) were reconstructed and reviewed. Results: Dynamic CTA demonstrated sufficient spatio-temporal resolution to elucidate first-pass and recirculation dynamics of contrast bolus through neurovasclaur pathologies and phasic blood flow though lower-limb vasculature and grafts. The high spatial resolution of fpVCT resulted in reduced partial volume and metal beam-hardening artefacts. This facilitated assessment of vascular lumen in the presence of calcified plaque and evaluation of fractures, especially in the presence of fixation hardware. Evaluation of arteriovenous malformation using dynamic fpVCT angiography was of limited utility. Conclusions: Dynamic CTA using fpVCT can visualize time-varying phenomena in neuro and lower limb vascular applications and has suffcient diagnostic imaging quality to evaluate a number of pathologies affecting these regions. Key Points: • CTA using fpVCT has sufficient spatial and temporal resolution to study phasic blood flow. • CTA using fpVCT reveals recurrence of aneurysms even after clipping/coiling. • fpVCT has reduced partial volume and metal beam-hardening artefacts. • fpVCT can show vessel lumen in the presence of calcified plaque. • CTA using fpVCT can demonstrate vascular supply to transplanted grafts. [ABSTRACT FROM AUTHOR]

Abstract: Limb ischaemia is a common clinical condition that causes considerable morbidity and mortality and represents a major drain on healthcare resources. Peripheral arterial disease (PAD) is the leading cause of both acute and chronic limb ischaemia. Chronic limb ischaemia may also be caused by non-atherosclerotic processes such as arterial entrapment, fibrosis or arteritis. Acute limb ischaemia may be also due to embolism, thrombosis or trauma. Duplex ultrasonography, computed tomography angiography and magnetic resonance angiography are now conventional forms of arterial imaging, with catheter angiography reserved for intervention. Risk factor modification is extremely important for all these patients, since many will also have significant coronary or cerebrovascular disease. Those with claudication often improve with structured exercise and if symptoms progress they may benefit from angioplasty or stenting. Arterial bypass remains the mainstay of treatment for patients with critical limb ischaemia if they are fit enough for surgery. Acute limb ischaemia is a surgical emergency and can be treated with surgical embolectomy or catheter-directed thrombolysis (depending on local expertise). Patients with irreversible limb ischaemia should be treated with primary amputation or palliation as appropriate. [Copyright &y& Elsevier]

Abstract: Objectives: To preoperatively determine candidates at definitive risk of postoperative delirium (POD), we identified relevant factors in patients with arteriosclerosis obliterans who underwent bypass surgery. Design: A prospective cohort study. Patients and methods: 299 patients (age ≥60 years) who underwent bypasses in 1995–2006 were enrolled. Cognitive impairment was assessed by the Revised Hasegawa Dementia Scale, the Confusion Assessment Method was also used, and severity was graded as Grade I–III (mild to severe) based on the Delirium Rating Scale. All patients were followed for 3 years. Results: POD occurred in 88 patients (29%), with a median age of 75 (10) years (IQR). Onset was 2 (1) days postoperatively, and a duration of 2 (2) days was observed. POD was hyperactive in 89% and was Grade I, II, and III in 11%, 68%, and 21% respectively. Multiple logistic regression analysis identified the following risk factors for POD: age ≥72 years (<0.0001), end-stage renal failure (0.001), multiple occlusive lesions (<0.0001), cognitive impairment (0.003), and critical limb ischaemia (0.034). The 3-year survival rate was similar when comparing POD and non-POD patients (84% vs. 88%, NS). Conclusions: This study identified 5 risk factors for POD in patients undergoing bypasses for limb ischaemia. Long-term outcomes were similar when comparing the patients who experienced POD with those who did not. [Copyright &y& Elsevier]

The potential vasodilator effect of the novel compound 2-alkylthio-4-ethyl-4-methyl-4,5 dihydro-1H-imidazolin-5-one oxime (oxime) was investigated in a model of lower limb ischaemia induced in rats by unilateral ligation of the right femoral artery using Laser Doppler Flowmetry. The effect of oxime was compared with that of isoprenaline or L-arginine. Test drugs were injected systemically into the femoral vein or applied locally on the planter surface of the rat hind paw. Serum level of nitrite (NO2 −) and nitrate (NO3 −) were measured by ELISA. Immediately after operative induction of right lower limb ischaemia, blood flow ratio (Right/Left limb ratio: BFR) decreased to 0.33−0.39 in different groups. The intravenous (i.v.) administration of oxime increased BFR in a dose-dependent manner. Compared with pre-drug BFR, oxime administered at doses of 0.064, 0.128 or 0.256 mg/kg increased BFR to 178.8, 328.9 and 705.9 %, respectively. Meanwhile, L-arginine given i.v. at 100 mg/kg increased BFR to 560 %. Isoprenaline given i.v. at 1 μg/kg increased BFR to 274.3 %, while isoprenaline combined with oxime (0.064 mg/kg) increased BFR to 402.7 %. Similarly, after topical application of oxime, BFR increased to 113.5, 261.1 and 433.3 %, respectively. L-arginine given at 1000 mg/kg increased BFR to 389.7 %. Isoprenaline given at 10 μg/kg increased BFR to 231.6 %, while isoprenaline administered in combination with oxime (0.064 mg/kg) increased BFR to 308.3 %. The concentration of NO in serum was significantly increased after systemic or topical administration of either 0.128 and 0.256 mg/kg oxime or 100 and 1,000 mg/kg L-arginine, respectively. It is concluded that systemic or topical oxime results in marked enhancement of blood flow in the rat ischaemic lower limb. This effect of oxime is likely to be mediated through the release of NO. [ABSTRACT FROM AUTHOR]

Objective: To describe 3 cases of vascular injuries due to orthopaedic procedures. Clinical Presentation and Intervention: Of 242 vascular injuries, 3 were due to orthopaedic screws. The 1st patient presented with a late complication (after 3 years) of an orthopaedic screw placed in close proximity to the axillary artery that with time got eroded and leaked to form a false aneurysm which later caused embolisation to the arm and limb ischaemia. The 2nd and 3rd cases were due acute ischaemia following the orthopaedic procedures. Both were injuries to the popliteal artery, one after a long screw and the other after drilling the tibia. The aneurysm of the 1st case was resected, the screw was removed and a reversed segment of the right long saphenous vein was used to repair the axillary artery. In the 2nd patient, a bypass of the left popliteal artery to the tibio-peroneal trunk was performed using a reversed 12-cm-long saphenous vein graft retrieved from the right thigh. In the 3rd patient, the right popliteal vein was ligated, and a reversed 25-cm-long saphenous vein graft retrieved from the left thigh was used for a femoro-popliteal bypass. For the 3 patients, postoperative recovery was unremarkable. Pulses were present within 6-10 months of follow-up. Conclusions: Whenever limb vascularity is compromised after an orthopaedic procedure, a high index of suspicion for an arterial injury should be exercised and prompt referral to the vascular service is mandatory. Repair of injured vessels with a saphenous vein graft provides excellent long-term results. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Since their introduction, biological glues have been more often used in cardiac and vascular surgery in order to control bleeding and reinforce surgical anastomotic sites. Report: We report a case of a 54-year-old woman diagnosed with acute limb ischaemia due to embolisation of biological glue, 45 days after her surgery for ascending aortic dissection. Her ischaemia was successfully relieved by an urgent thrombectomy. Discussion: Complications due to the use of biological glues remain rare but are very serious. Preventive measures and intra-operative precautions must be considered in order to avoid most of these complications. [Copyright &y& Elsevier]

Abstract: Introduction: Thorascopic sympathectomy is a widely used procedure for the treatment of intractable palmar hyperhidrosis. Report: A 24-year-old woman who underwent thorascopic sympathectomy for hyperhidrosis in 2005 presented on more than 30 occasions with recurrent right distal upper limb ischaemia secondary to repetitive episodes of vasospasm. The patient did not have preoperative symptoms consistent with Raynaud’s syndrome. We observed a reduction in the symptomatic relief offered by Iloprost treatment over a period of five years. Discussion: This is the first report of distal upper limb ischaemia following thorascopic sympathectomy. We highlight the development of resistance to repeated Iloprost infusions that we observed in this case. [Copyright &y& Elsevier]

Rectal cancer and cardiovascular disease are both commoner in the elderly and may coexist. In some severe arteriopaths the blood supply to the lower limbs may be a collateral circulation from the inferior mesenteric artery. Patients with aorto-iliac occlusion or severe stenosis may have collaterals from the inferior mesenteric artery to the lower limb blood vessels. Ligation of the inferior mesenteric artery in treating rectal cancer can result in irreversible ischaemia as outlined in this report. Routine palpation of the femoral pulses and awareness of collateral circulation may avoid the disastrous consequences seen in the two cases described. [ABSTRACT FROM AUTHOR]

Currently available drug therapies for patients suffering severe ischaemia with rest pain and trophic lesions of the limbs remain unsatisfactory. Also vascular reopening procedures are suitable in only about half of the patients. In atherosclerotic disease when the vascular endothelium is damaged prostacyclin synthesis is decreased and thromboxane A2 production increases. Prompted by this knowledge of the importance of prostacyclin in pathogenesis of atherosclerotic disease an attempt was made to employ PGI2 clinically – for treatment of advanced forms of peripheral arterial atherosclerotic disease. Favourable effects of the stable analogue of prostacyclin (Iloprost), were reported in various studies, which included patients with peripheral atherosclerotic arterial disease, thromboangiitis obliterans and Raynaud’s phenomenon. The use of Iloprost resulted in a significantly superior response than other drugs and placebo in terms of alleviation of rest pain, ulcer healing and decrease of amputation rate of ischaemic limbs. Therefore prostacyclin provides a therapeutic option in patients with advanced forms of arterial disease – including critical ischaemia. [ABSTRACT FROM AUTHOR]

Abstract: Different studies have provided evidence that implantation of bone-marrow mononuclear cells (BM-MNC) into ischaemic limbs can improve tissue vascularization. Based on these results we performed a pilot study in patients with critical lower limb ischaemia to assess efficacy and safety of implantation of autologous BM-MNC. The amount and efficacy of BM-MNC purified either by an automated method or by a manual procedure were compared. Twelve patients with severe unilateral lower limb ischaemia were entered into this study. They were randomly assigned to be injected with BM-MNC sorted on a blood cell separator or isolated by density gradient on Ficoll–Hypaque. BM-MNC were implanted into the ischaemic legs. Patients were monitored with resting ankle-brachial pressure index (ABI), arterial oxygen saturation (SaO2), pain-free walking time and rest pain scale evaluation. The automated and manual methods used for mononuclear cell separation gave results not significantly different. Monitored variables improved in both groups. Improvement of ischaemic condition persisted during 24 weeks follow-up. Limb salvage was achieved in five cases. Our results indicate that BM-MNC implantation into ischaemic limbs is a practical, safe and effective method that may significantly contribute to the management of patients with limb ischaemia. The Ficoll method is a simple and effective procedure for BM-MNC concentration that may be useful, mainly in hospitals without sophisticated facilities. [Copyright &y& Elsevier]