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Objectives Long-segment stenting of the infrarenal aorta and bilateral iliac arteries, with or without femoral endarterectomy for diffuse disease, has been adopted for treatment of severe aortoiliac occlusive disease (AIOD). The objective of this study was to compare outcomes of this reconstruction, termed aortoiliac stenting with bifurcation reconstruction (AISBR), to aortobifemoral bypass (ABF) in patients with comparable TASC II D lesions. Methods This is a single-center, retrospective review of patients treated with ABF or AISBR for comparable TASC II D lesions between 2010 and 2018. ABF patients were included only if they were deemed anatomic candidates also for AISBR after review of preoperative imaging. Patients treated for acute limb ischemia and bypass graft infection were excluded. Statistics included Fisher exact test, Kaplan-Meier analysis, and Cox proportional hazards regression. Results There were 24 ABF and 75 AISBR included in the study. The primary indication for treatment was claudication in 55 (55.6%) patients, rest pain in 28 (28.3%), and tissue loss in 16 (16.2%). Patients undergoing AISBR were more likely to be female. Femoral endarterectomies were performed in 37/75 (49.3%) AISBR and 14/24 (58.3%) ABF (p=0.44). AISBR were performed percutaneously in 34/75 (45.1%). No AISBR required conversion to ABF. Intraoperative blood loss, procedure time and hospital length of stay (LOS) were significantly less for AISBR compared to ABF. Surgical site infections (SSI) were less common in patients undergoing AISBR (AISBR: 6/75 (8.0%) vs. ABF: 9/24 (37.5%), (p 30 days postoperatively. The reductions in blood loss, LOS and SSI remained significant after excluding percutaneous AISBR from the analysis. Five-year primary patency was 50.8% (95% CI: 33.3, 68.4%) for AISBR and 88.1% (72.7, 100.0%) for ABF (p=0.04). Five-year survival was 76.5% (95% CI: 63.6, 89.5) for AISBR and 100% (95% CI: 100.0, 100.0) for ABF (p = 0.07). Five-year primary assisted patency, secondary patency, freedom from reintervention and major adverse limb events did not differ significantly between groups. Conclusions AISBR is a viable option for management of TASC II D AIOD, with lower morbidity and acceptable durability when compared to traditional ABF.

PURPOSE: Percutaneous cannulation is increasingly used for veno-arterial extracorporeal membrane oxygenation (VA-ECMO). However, there is limited evidence about the benefit of this approach compared with conventional surgical cannulation. By using a large international database, this study was designed to compare in-hospital outcomes in cardiac shock patients who received femoro-femoral VA-ECMO with percutaneous versus surgical cannulation.METHODS: Adults with refractory cardiogenic shock treated with percutaneous (percutaneous group) or surgical (surgical group) femoro-femoral VA-ECMO between January 2008 and December 2019 were extracted from the international Extracorporeal Life Support Organization registry. The primary outcome was in-hospital mortality. Multivariable logistic regression analyses were performed to assess the association between percutaneous cannulation and in-hospital outcomes.RESULTS: Among 12,592 patients meeting study inclusion, 9,249 (73%) underwent percutaneous cannulation. The proportion of patients undergoing percutaneous cannulation increased from 32% to 84% over the study period (p < 0.01 for trend). In-hospital mortality (53% vs 58%; p < 0.01), cannulation site bleeding (19% vs 22%; p < 0.01), and systemic infection (8% vs 15%; p < 0.01) occurred less frequently in the percutaneous group compared to the surgical group. In adjusted analyses, percutaneous cannulation was independently associated with lower rates of in-hospital mortality (odds ratio [OR] 0.76; 95% CI 0.70-0.84; p < 0.01), cannulation site bleeding (OR 0.70; 95% CI 0.60-0.80; p < 0.01) and systemic infection (OR, 0.63; 95% CI 0.54-0.74; p < 0.01). Severe limb ischemia was more frequently observed in the percutaneous group (5% vs 3%; p < 0.01). However, this association was not significant in adjusted analysis (OR 1.28; 95% CI 0.93-1.62; p = 0.15).CONCLUSIONS: Compared with surgical cannulation, percutaneous cannulation was independently associated with lower in-hospital mortality and fewer complications.

A variable clinical presentation is emerging as a hallmark of the novel SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). In addition to hypoxic respiratory failure, multiorgan dysfunction, and septic shock, significant thromboembolic complications posited to result from diffuse coagulopathy have been associated with this viral infection. We report on a unique primary manifestation of SARS-CoV-2 infection presenting as acute limb ischemia and aortic mural thrombosis without clinical evidence of pulmonary disease. Despite our best attempts at limb salvage with therapeutic anticoagulation, emergent aortoiliac and distal embolectomy, the patient developed bilateral dry gangrene and ultimately required lower extremity amputations.

Aim: The aim of the current study was to describe the clinical profile, frequency of in-hospital complications, and predictors of adverse events in patients undergoing endovascular therapy (EVT) for acute limb ischemia (ALI), and to compare them with those of patients undergoing EVT for chronic symptomatic peripheral artery disease (PAD). Methods: The current study compared 2,398 cases of EVT for ALI with 74,171 cases of EVT for chronic symptomatic PAD performed between January 2015 and December 2018 in Japan. We first compared the clinical profiles of ALI patients with those of PAD patients. We then evaluated the proportion of in-hospital complications and investigated their risk factors in the ALI patients. The association of clinical characteristics with the risk of in-hospital complications was analyzed via logistic regression modeling. Results: Patients with ALI were older and had a higher prevalence of female sex, impaired mobility, and history of cerebrovascular disease, but a lower prevalence of cardiovascular risk factors and history of coronary artery disease. The proportion of in-hospital EVT-related complications in ALI was 6.1% and was significantly higher compared with those in chronic symptomatic PAD patients (2.0%, P ＜0.001). Bedridden status (adjusted odds ratio [aOR], 1.74 [1.14 to 2.66]; P =0.010), history of coronary artery disease (aOR, 1.80 [1.21 to 2.68]; P =0.004), and a suprapopliteal lesion (aOR, 1.70 [1.05 to 2.74]; P =0.030) were identified as independent risk factors for in-hospital complications. Conclusion: The current study demonstrated that ALI patients with significant comorbidities show a higher proportion of in-hospital complications after EVT.

Chronic limb-threatening ischemia requires aggressive risk factor management and a thoughtful approach to the complex decision of best strategy for revascularization. Patients often have multilevel disease amenable to endovascular, open surgical, or hybrid approaches. Limited high-quality evidence is available to support a specific strategy; randomized trials are ongoing. Acute limb ischemia is associated with a high risk of limb loss and mortality. Catheter-directed thrombolysis is mainstay of therapy in patients with marginally threatened limbs, whereas those immediately threatened with motor deficits require more rapid restoration of flow with open or endovascular techniques that can establish flow in single setting.

Background: Following severe limb ischemia requiring urgent/emergent revascularization, peripheral arterial disease patients suffer a high risk of recurrent atherothrombosis. Methods: Patients discharged from Hamilton General Hospital (Hamilton, Ontario) between April 2016 and September 2017 following severe limb ischemia requiring urgent/emergent revascularization were identified via the Local Health Integration Network CorHealth database, with supplemental information from chart review. Results: A total of 158 patients admitted for urgent/emergent revascularization were identified (148 alive at discharge). Among patients without a pre-existing indication for anticoagulation, 38.8% (n = 47) were discharged on single-antiplatelet therapy, 27.3% (n = 33) on dual-antiplatelet therapy, 19.8% (n = 24) on anticoagulants plus antiplatelet therapy, 6.6% (n = 8) on anticoagulants alone, and 2.6% (n = 3) on unknown therapy. Patients who received angioplasty with stenting were more likely be discharged on dual-antiplatelet therapy (hazard ratio [HR]: 7.14; 95% confidence interval [CI]: 2.87-17.76; P < 0.01); patients who received an embolectomy/thrombectomy were more likely be discharged on an anticoagulant alone (HR: 2.61; 95% CI: 1.00-6.81; P = 0.049); and patients who received peripheral bypass grafting were more likely be discharged on single-antiplatelet therapy (HR: 2.28; 95% CI: 1.11-4.69; P = 0.024). Neither statins (60.8% vs 56.3%; P = 0.23) nor renin–angiotensin–aldosterone system inhibitors (48.7% vs 50.6%; P = 0.58) were prescribed at higher rates at discharge, compared with the rate at admission. Conclusions: Substantial heterogeneity exists in antithrombotic prescription following urgent/emergent revascularization. No intensification of non-antithrombotic vascular protective medications occurred during hospitalization. Clinical trials and health system interventions to optimize medical therapy in peripheral arterial disease patients are urgently needed. Résumé: Introduction: Après une ischémie grave d’un membre ayant nécessité une revascularisation urgente/nouvelle revascularisation, les patients atteints d’une maladie artérielle périphérique ont un risque élevé de récidive d’athérothrombose. Méthodes: Nous avons recensé les patients qui ont obtenu leur sortie de la Hamilton General Hospital (Hamilton, Ontario) entre avril 2016 et septembre 2017 à la suite d’une ischémie grave d’un membre ayant nécessité une revascularisation urgente/nouvelle revascularisation via la base de données Local Health Integration Network CorHealth et grâce aux renseignements complémentaires issus de la revue des dossiers. Résultats: Nous avons recensé un total de 158 patients admis pour une revascularisation urgente/nouvelle revascularisation (148 patients en vie à la sortie de l’hôpital). Parmi les patients chez lesquels l’anticoagulation n’avait pas antérieurement été indiquée, 38,8 % (n = 47) avaient reçu à leur sortie de l’hôpital un simple traitement antiplaquettaire; 27,3 % (n = 33), une bithérapie antiplaquettaire; 19,8 % (n = 24), des anticoagulants plus un traitement antiplaquettaire; 6,6 % (n = 8), des anticoagulants seuls; 2,6 % (n = 3), un traitement inconnu. Les patients qui avaient subi une angioplastie et une pose d’endoprothèse étaient plus susceptibles d’obtenir à leur sortie de l’hôpital une bithérapie antiplaquettaire (rapport de risque [RR] : 7,14; intervalle de confiance [IC] à 95 % : 2,87-17,76; P < 0,01); les patients qui avaient subi une embolectomie, ou thrombectomie, étaient plus susceptibles d’obtenir à leur sortie de l’hôpital un anticoagulant seul (RR : 2,61; IC à 95 % : 1,00-6,81; P = 0,049); les patients qui avaient subi un pontage périphérique étaient plus susceptibles d’obtenir à leur congé de l’hôpital un simple traitement antiplaquettaire (RR : 2,28; IC à 95 % : 1,11-4,69; P = 0,024). Comparativement à l’admission, ni les statines (60,8 % vs 56,3 %; P = 0,23) ni les inhibiteurs du système rénine–angiotensine–aldostérone (48,7 % vs 50,6 %; P = 0,58) n’avaient été prescrits à des taux plus élevés à la sortie de l’hôpital. Conclusions: Nous observons une hétérogénéité substantielle de l’ordonnance des antithrombotiques après la revascularisation urgente/nouvelle revascularisation. L’hospitalisation n’a donné lieu à aucune augmentation des médicaments de protection vasculaire non antithrombotiques. Des essais cliniques et des interventions du système de santé qui permettent d’optimiser le traitement médical des patients atteints d’une maladie artérielle sont d’une urgente nécessité.

Aortic thrombus with multilevel acute ischemia is rare. We report the use of vacuum-assisted thrombectomy of an aortic mural thrombus with superior mesenteric artery involvement causing bilateral lower extremity ischemia and acute mesenteric ischemia, in conjunction with embolectomy and fasciotomy. We describe the novel use of the AngioVac device (AngioDynamics, Latham, NY) for reperfusion in the systemic arterial circulation. This case report demonstrates a feasible and less invasive alternative to the management of aortic thrombi with acute ischemia in patients unfit for open aortic thrombectomy of the visceral segment aorta.

Objectives The aim of this study was to evaluate the interaction between hospital endovascular lower extremity revascularization (eLER) volume and outcomes after eLER for critical limb ischemia (CLI). Background There is a paucity of data on the relationship between hospital procedural volume and outcomes of eLER for CLI. Methods The authors queried the Nationwide Readmission Database (2013-2015) for hospitalized patients who underwent eLER for CLI. Hospitals were divided into tertiles according to annual eLER volume: low volume ( 550 eLER procedures). Stepwise multivariable regression models were used. The main outcomes were in-hospital mortality and 30-day readmission with major adverse limb events, defined as the composite of amputation, acute limb ischemia, or repeat revascularization. Results Among 145,785 hospitalizations for eLER for CLI, 5,199 (3.6%) were at low-volume eLER hospitals, 27,857 (19.1%) at moderate-volume eLER hospitals, and 112,728 (77.3%) at high-volume eLER hospitals. On multivariable analysis, there was no difference with regard to in-hospital mortality among moderate-volume hospitals (adjusted odds ratio [OR]: 0.78; 95% CI: 0.60-1.01) and high-volume hospitals (adjusted OR: 0.84; 95% CI: 0.64-1.05) compared with low-volume hospitals. There was lower risk of in-hospital major amputation (adjusted OR: 0.82; 95% CI: 0.70-0.96) and minor amputation at high- versus low-volume hospitals. The length of hospital stay was shorter and discharges to nursing facilities were fewer among moderate- and high-volume hospitals compared with low-volume hospitals. Compared with low-volume hospitals, eLER for CLI at high-volume hospitals had a lower risk for 30-day readmission with major adverse limb events (adjusted OR: 0.83; 95% CI: 0.70-0.99), while there was no difference among moderate-volume hospitals (adjusted OR: 0.92; 95% CI: 0.77-1.10). Conclusions This nationwide observational analysis suggests that annual eLER volume does not influence in-hospital mortality after eLER for CLI. However, high eLER volume (>550 eLER procedures) was associated with better rates of limb preservation after eLER for CLI.

Congenital atresia of the common and external iliac arteries is an extremely rare vascular anomaly, although often associated with limb ischemia and genitourinary malformations. We have presented a rare case of the congenital absence of the left common and external iliac arteries, with no limb ischemic symptoms or organ anomalies present.

Background: Treatment of chronically occluded infrainguinal venous bypass grafts in patients presenting with recurrent chronic limb threatening limb ischemia (CLTI) represent a clinical challenge. Recent case reports have suggested the use of endovascular recanalization techniques without preceding thrombolysis. This study assesses feasibility and mid-term outcomes of this technique. Results: A retrospective review of 5 consecutive patients (3 men, 2 women, mean age 70 ± 5 years) presenting with chronic venous bypass graft occlusion and recurrence of CLTI during 1 year was performed. Patients were treated with relining of the bypass grafts. Patients were followed up at median 26 (6–36) months. All patients were treated successfully with restoration of flow in the grafts using recanalization and relining technique without thrombolysis. In 4 patients, a Viabahn stentgraft (SG) was used with the addition of interwoven nitinol stents (INS) in 3. In 1 patient, the graft was treated with INS without the addition of a stentgraft. No peripheral embolization was encountered during the procedures. One patient occluded the relined grafts after 6 months. The remaining 4 grafts were all patent at 24-month follow-up. A total of 6 reinterventions (in 3 patients) were performed to reach 80% secondary patency. Conclusions: This case series demonstrate feasibility and promising mid-term results, from relining of chronically occluded infra-inguinal venous bypass grafts using stent grafts, interwoven and bare-metal stents without preceding thrombolysis. The technique could be an alternative treatment option in the treatment of these challenging cases. (Less)

BACKGROUND Limb ischemia is a major complication of femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO). Use of ankle-brachial index (ABI) to monitor limb perfusion in VA-ECMO has not been described. We report our experience monitoring femoral VA-ECMO patients with serial ABI and the relationships between ABI and near infrared spectroscopy (NIRS). METHODS This is a retrospective single-center review of consecutive adult patients placed on femoral VA-ECMO between January 2019 and October 2019. Data were collected on patients with paired ABI and NIRS values. Relationships between NIRS and ABI of the cannulated (E-NIRS and E-ABI) and non-cannulated legs (N-NIRS and N-ABI) along with the difference between legs (d-NIRS and d-ABI) were determined using Pearson correlation. RESULTS Overall, 22 patients (mean age 56.5 ± 14.0 years, 72.7% male) were assessed with 295 E-ABI and E-NIRS measurements, and 273 N-ABI and N-NIRS measurements. Mean duration of ECMO support was 129.8 ± 78.3 h. ECMO-mortality was 13.6% and in-hospital mortality was 45.5%. N-ABI and N-NIRS were significantly higher than their ECMO counterparts (ABI mean difference 0.16, 95% confidence interval [CI]: 0.13-0.19, p

This literature review discusses the current evidence on acute limb ischemia (ALI) in patients with COVID-19. Throughout the pandemic, these patients have been at increased risk of arterial thrombotic events and subsequent mortality as a result of a hypercoagulable state. The exact mechanism of thrombosis is unknown; however arterial thrombosis may be due to invasion of endothelial cells via angiotensin-converting enzyme 2 (ACE2) receptors, endothelial injury from inflammation, or even free-floating aortic thrombus. Multiple studies have been performed evaluating the medical and surgical management of these patients; the decision to proceed with operative intervention is dependent on the patient's clinical status as it relates to COVID-19 and morbidity of that disease. The interventions afforded typically include anticoagulation in patients undergoing palliation; alternatively, thrombectomy (endovascular and open) is utilized in other patients. There is a high risk of rethrombosis, despite anticoagulation, given persistent endothelial injury from the virus. Postoperative mortality can be high in these patients.

Persistent sciatic artery (PSA) is an extremely rare vascular phenomenon, with a prevalence of 0.025% to 0.04% in the general population. We present the case of a 72-year-old man with a thrombus-containing PSA aneurysm that caused embolic acute limb ischemia. We also discussed the PSA classification systems, common presentations, rarity of the pathology, and high rates of severe complications.

We have reported a case of delayed hip prosthetic erosion into the common femoral artery (CFA) 3 years after implantation. The patient had initially presented with left lower extremity acute limb ischemia secondary to a popliteal artery embolism. However, the metal artifact around the hip joint prevented CFA evaluation using conventional imaging. Diagnostic angiography with intraoperative intravascular ultrasound revealed CFA dilatation with adherent intraluminal thrombus. Open surgical repair showed hip prosthesis erosion through the posterior wall of the CFA. Our findings emphasize the necessity for a thorough, multimodal embolic workup and the usefulness of intravascular ultrasound as an adjunctive tool for intravascular anatomy evaluation.

Objectives Determine if shortening the covered section of a self-expanding bidirectional arterial cannula, can enhance retrograde flow and thus reduce the risk of lower limb ischemia. Methods Outlet pressure vs flow rate was determined for three cannulas types: a 15F self-expanding bidirectional cannula having a covered section of 90 mm, the same cannula but with a shorter covered section of 60 mm, and a Biomedicus cannula as control. The performances of all the cannulas were compared using a computerized flow-bench with calibrated sensors and a centrifugal pump. Water retrograde flow was determined using a tank timer technique. Anterograde and retrograde flow rate versus outlet pressure were determined at six different pump speed. Results For each of the six pump speed, both bidirectional cannulas, 60-mm covered and 90-mm covered respectively, showed higher performance than Biomedicus cannula control, as demonstrated by higher flow rate and lower pressure. We also observed that for the bidirectional cannula with shorter covered section, i.e. 60 mm coverage, provides enhanced performance as compared to a 90-mm coverage. Finally, the flow rate and the corresponding pressure can be consistently measured by our experimental set-up with low variability. Conclusions The new configuration of a shorter covered section in a bidirectional self-expanding cannula design, may present an opportunity to overcome lower leg ischemia during extra-corporal life support with long term peripheral cannulation.

Background: The aim of this study was to evaluate the ipsilateral lower extremity (ILE) outcomes of patients who underwent bedside angiography via the distal perfusion catheter while on femoral veno-arterial extracorporeal membrane oxygenation (VA ECMO). Methods: This is a retrospective analysis of all patients placed on VA ECMO at a single center from January 2017 to December 2019 who underwent bedside angiography via the distal perfusion catheter. Results: Twenty-four patients underwent bedside angiography via the distal perfusion catheter after being placed on VA ECMO. A vasodilator was directly administered in three patients for suspected spasm. One patient had distal thrombus and underwent thrombectomy and fasciotomy. One patient had a dislodged catheter and underwent thrombectomy, fasciotomy, and replacement of the catheter. One patient had severe ILE ischemia, however was not intervened upon due to critical acuity. Finally, one patient had inadvertent placement in the saphenous vein and had a new catheter placed in the SFA. No patients underwent amputation. Ultimately, 21 patients (87.5%) had no ILE compromise at the end their ECMO course. Survival to decannulation was 66.7% ( n = 16). Conclusions: Bedside angiography of the distal perfusion catheter is feasible and can be a useful adjunct in informing the need for further intervention to the ILE. Classifications: extracorporeal membrane oxygenation, ischemia

Background: Degenerative superficial femoral artery aneurysms are rare and can lead to catastrophic complications; among these, rupture is the most usual, whereas peripheral embolization is less common. Method: We report a patient with a large superficial femoral artery aneurysm presenting with irreversible limb ischemia, due to multiple distal embolization as demonstrated with urgent computed tomography angiography. Due to local and systemic consequences primary limb amputation was performed. Unfortunately, the patient died from cardiac arrest on the 2nd postoperative day. Conclusion: Delayed diagnosis of true superficial femoral artery aneurysms can result in life-threatening consequences. Peripheral embolization is an uncommon event, but can lead to irreversible ischemia and limb loss.

Critical limb ischemia (CLI) is a severe state of peripheral artery disease with high unmet clinical needs. Further, there are no effective treatment options for patients with CLI. Based on preclinical study results, predicting the clinical efficacy of CLI treatments is typically difficult because conventional hindlimb ischemia (HLI) rodent models display spontaneous recovery from ischemia, which is not observed in patients with CLI. Therefore, we aimed to develop a novel chronic and severe HLI model to properly evaluate the therapeutic effects of drug candidates for CLI. Severe HLI mice (Type-N) were generated by increasing the excised area of blood vessels in a hindlimb of NOG mice. Immunohistochemistry and gene expression analysis at 9 wk after the Type-N operation revealed that the ischemic limb was in a steady state with impaired angiogenesis, like that observed in patients with CLI. We did selection of chronic Type-N mice based on the number of necrotic nails and blood flow rate at 2 wk after surgery because some Type-N mice showed mild symptoms. Therapeutic treatment with cilostazol, which is used for intermittent claudication, did not restore blood flow in chronic Type-N mice. In contrast, therapeutic transplantation of pericytes and vascular endothelial cells, which can form new blood vessels in vivo, significantly improved blood flow in a subset of Type-N mice. These findings suggest that this novel chronic and severe HLI model may be a valuable standard animal model for therapeutic evaluation of the angiogenic effects of CLI drug candidates.

The diagnosis and treatment of acute limb ischemia (ALI) has long been a fierce adversary that has evolved over the last several decades with scientific advancements in endovascular therapy. History and physical examination remain the mainstay of diagnosis enhanced by detailed imaging to guide therapy. Many endovascular tools are available for prompt restoration of flow that compliment traditional surgical options. These devices incorporate the mechanical removal of thrombus and the chemical dissolution of thrombus . Medical decision-making for ALI patients must take into account the patient characteristics, anatomic variables, mechanism of ischemia, degree of ischemia, and operator skill to employ the right strategy for the right patient. This moving target challenges scientific study, making the therapeutic bedside decision making an artform. We present an overview of the field, supportive data, and a treatment algorithm that hopefully captures this delicate balance.

AngioJet rheolytic thrombectomy, although a successful treatment modality for arterial thrombus removal and recanalization, has been shown to have increased rates of postoperative acute kidney injury (AKI) compared with other methods of treatment for acute limb ischemia. The postinterventional course of AKI can differ markedly from patient to patient, but typically resolves relatively quickly. Herein, we present a case of AKI secondary to AngioJet intervention that demonstrates an exceedingly prolonged but ultimately recoverable course with conservative management and without the need for renal replacement therapy.

Thrombotic complications associated with coronavirus disease 2019 (COVID-19) have been described; these have mainly included venous thromboembolic events. Limited literature is available regarding arterial thrombosis. Acute limb ischemia is associated with severe complications that can result in significant morbidity and mortality. Herein, we report 3 cases of COVID-19 infection complicated by arterial thrombosis in the form of acute limb ischemia. Our case series adds to the limited literature regarding arterial thrombosis.

Introduction COVID-19 infection is commonly complicated with pro-thrombotic state and endothelial dysfunction. While several studies reported a high incidence of venous thromboembolic events. The occurrence of arterial thromboses are yet rarely described and could be underestimated. Objectives To describe the clinical and biological characteristics of COVID-19 patients presenting with an associated arterial thromboembolic event. Material and methods We performed a retrospective multicentric study in 3 centers between France and Italy. All patients with a confirmed SARS-CoV-2 infection and arterial thromboembolic events were included in the analysis. Results From March 8th to April 25th 2020, we identified 20 patients (24 events) with arterial thromboembolic events over 209 admitted patients (9.6%) with severe COVID-19 infection. Arterial thrombotic events included acute coronary occlusions (n = 9), stroke (n = 6), limb ischemia (n = 3), splenic infarcts (n = 3), aortic thrombosis (n = 2) and occlusive mesenteric ischemia (n = 1). At the time of the event, 10/20 (50%) of patients received thromboprohylaxis, 2/20 (10%) were receiving treatment dose anticoagulation and 5/20 (25%) were receiving antiplatelet therapy. Conclusion Our observations suggest that serious arterial thrombotic events might occur in Covid-19 patients. However, the exact incidence of such events and the best way to prevent them yet remains to be investigated., Highlights • SARS-CoV-2 infection is commonly complicated with pro-thrombotic state and endothelial dysfunction. • High rate of venous thromboembolic events have been described among patients suffering from Covid-19. However, arterial thromboses are yet rarely described in this setting. • We report a total of 20 cases of COVID-19 patients suffering from arterial thromboses. • Our observations suggest that arterial thrombotic events might occur in Covid-19 patients and could be underestimated.

Management of pediatric iatrogenic arterial occlusions can be challenging clinically, leading to chronic complications such as claudication and limb length discrepancy. We report the case of a 6-month-old female patient who had experienced iatrogenic right external iliac and common femoral arterial occlusion. At the age of 8 years, she had developed claudication and a limb length discrepancy of 3.2 cm. She underwent common iliac artery to superficial femoral artery and profunda artery bypass via a branched autologous reverse great saphenous vein using microsurgical techniques for the distal anastomoses. In the present report, we have focused on the musculoskeletal improvements, benefits of microsurgery in pediatric vessels, and maximization of epiphyseal perfusion.

Background: The angiogenic response to ischemia restores perfusion so as to preserve tissue. A role for mesenchymal-to-endothelial transition in the angiogenic response is controversial. This study is to determine if resident fibroblasts contribute to angiogenesis. Methods: We utilized the murine model of hindlimb ischemia, and in vivo Matrigel plug assay together with lineage tracing studies and single cell RNA-sequencing to examine the transcriptional and functional changes in fibroblasts in response to ischemia. Results: Lineage tracing using Fsp1-Cre: R26R-EYFP mice revealed the emergence within the ischemic hindlimb of a small subset of YFP + CD144 + CD11b − fibroblasts (E* cells) that expressed endothelial cell (EC) genes. Subcutaneous administration of Matrigel in Fsp1-Cre: R26R-EYFP mice generated a plug that became vascularized within 5 days. Isolation of YFP + CD11b - cells from the plug revealed a small subset of YFP + CD144 + CD11b − E* cells which expressed EC genes. Pharmacological or genetic suppression of innate immune signaling reduced vascularity of the Matrigel plug and abrogated the generation of these E* cells. These studies were repeated using human fibroblasts, with fluorescence-activated cell sorting analysis revealing that a small percentage of human fibroblasts that were induced to express EC markers in Matrigel plug assay. Pharmacological suppression or genetic knockout of inflammatory signaling abolished the generation of E* cells, impaired perfusion recovery and increased tissue injury after femoral artery ligation. To further characterize these E* cells, single cell RNA-sequencing studies were performed and revealed 8 discrete clusters of cells expressing characteristic fibroblast genes, of which 2 clusters (C5 and C8) also expressed some EC genes. Ischemia of the hindlimb induced expansion of clusters C5 and C8. The C8 cells did not express CD144, nor did they form networks in Matrigel, but did generate angiogenic cytokines. The C5 fibroblasts most resembled E* cells in their expression of CD144 and their ability to form EC-like networks in Matrigel. Conclusions: Together, these studies indicate the presence of subsets of tissue fibroblasts which seem poised to contribute to the angiogenic response. The expansion of these subsets with ischemia is dependent on activation of innate immune signaling and contributes to recovery of perfusion and preservation of ischemic tissue.

A 61-year-old man presented with chronic limb threatening ischemia due to reocclusion of a femoropopliteal (FP) bypass using a saphenous vein graft (SVG). After performing endovascular intervention using plain angioplasty and drug-coated balloon and drug-eluting stent implantation of the proximal anastomosis of FP bypass, refractory early reocclusion occurred during the perioperative period. Thus, we decided to alternatively place a stent-graft in the occluded FP bypass. After the SVG had been dilated using a high-pressure balloon, a stent-graft was successfully placed. This alternative therapy using a stent-graft prevented SVG FP bypass reocclusion, and the patient's ulcers had completely healed within 1 month.

For the management of acute limb ischemia (ALI) and multilevel arterial occlusive disease, tibial bypass using the saphenous vein has been considered a mainstay due to the long-term durability in selected patients with acceptable saphenous veins and comorbid conditions. Traditionally, bypass using a varicose autogenous graft has been contraindicated due to the risk of late aneurysmal dilation and rupture. Here, we describe a patient who presented with ALI and received tibioperoneal trunk bypass using a varicose autogenous graft. The patient has been doing well during the 72-month follow-up without recurrent symptoms or revision. The follow-up images showed a favorably patent graft with mild aneurysmal changes at the valve cusp adjacent to the knee. If there are no other appropriate autologous veins for revascularization, a varicose autogenous vein graft may be a useful option for limb salvaging in selected patients with multilevel arterial occlusive diseases.

Introduction: The criteria for placement of distal perfusion cannulas vary among reports. This cohort study aimed to establish a reproducible method to monitor critical leg ischemia during minimally invasive cardiac surgery. Methods: We included 121 patients who underwent minimally invasive cardiac surgery via right thoracotomy with right femoral arterial cannulation from 2015 to 2018. The change rate of regional oxygen saturation (ΔrSO2) was calculated as follows: rSO2 (baseline) − rSO2 (actual number)/rSO2 (baseline). Patients were divided into Group N (ΔrSO2 2 > 40%, 40%): 21/121 (17%). A distal perfusion cannula was placed when ΔrSO2 was >40% over 10 minutes. Results: No patients experienced significant leg ischemia. Significantly longer cardiopulmonary bypass and aortic cross-clamp times were observed in Group H than in Group N (cardiopulmonary bypass time, 129 ± 36 minutes (Group N) vs. 151 ± 34 minutes (Group H), p = 0.01). ΔrSO2 correlated positively with plasma creatine phosphokinase elevation (R = 0.40, p 2. Conclusion: ΔrSO2 measurement by near-infrared spectroscopy can facilitate distal leg perfusion monitoring and assist surgeons in preventing critical leg ischemia during minimally invasive cardiac surgery.

Objective Plateletcrit (PCT) reflects the total platelet mass in blood and can be calculated from a complete blood count. We examined the effect of PCT on outcomes of endovascular and open interventions for chronic limb ischemia. Methods Patients who underwent revascularization for chronic limb ischemia (Rutherford categories 3-6) between June 2001 and December 2014 were retrospectively identified. PCT on admission was recorded. Patients and limbs were divided into tertiles of low (0.046-0.211), medium (0.212-0.271), and high (0.272-0.842) PCT. Patency, limb salvage, major adverse limb events, major adverse cardiac events, and survival rates were calculated using Kaplan-Meier analysis and compared with log-rank test. Cox regression analysis was used for multivariate analysis. Results A total of 1431 limbs (1210 patients) were identified and divided into low PCT (477 limbs in 407 patients), medium PCT (477 limbs in 407 patients), and high PCT (477 limbs in 396 patients) groups. The patients in the high tertile were 2 years older that the patients in the other two tertiles (P = .009). Five-year primary patency was 65% ± 3% in the low-PCT group compared with 55% ± 3% and 51% ± 3% in the medium and high PCT groups, respectively (P = .004). Five-year secondary patency was 81% ± 2% in the low PCT group compared with 82% ± 2% and 72% ± 3% in the medium and high PCT groups, respectively (P = .02). Five-year limb salvage rate was 86% ± 2% in the low PCT group compared with 79% ± 3% and 74% ± 3% in the medium PCT and high PCT groups, respectively (P = .004). Multivariate regression analysis showed that low PCT was independently associated with primary patency after endovascular interventions (hazard ratio, 0.67 [0.47-0.95]; P = .02) but not after open interventions (hazard ratio, 0.72 [0.43-1.21]; P = .21). Conclusions High PCT is associated with poor patency and limb salvage rates after interventions for lower extremity chronic limb ischemia. Multivariate regression analysis confirmed association of low PCT with improved primary patency after endovascular interventions but not after open interventions. High PCT may be a marker of increased platelet reactivity and could be used to identify patients at high risk for early thrombosis and failure after interventions.

Phlegmasia cerulea dolens can be a potentially devastating complication of severe deep venous thrombosis leading to limb ischemia and tissue necrosis. This report describes a patient presenting with phlegmasia cerulea dolens of the right lower extremity. Because of the urgent nature of the condition, percutaneous nonpharmacologic mechanical thrombectomy in a single session was pursued. Extensive thrombus burden was removed from the patient, and vessel patency was restored after balloon venoplasty. The patient's symptoms rapidly resolved, and the targeted vessels remain patent at 3-month follow-up.

Acute limb ischemia (ALI) related to pheochromocytoma is rare. We describe a 69-year-old woman who presented with ALI due to a thromboembolic phenomenon from new-onset atrial fibrillation that was successfully treated with intra-arterial catheter-directed lysis and systemic anticoagulation. Further workup revealed a left adrenal mass and biochemical test results consistent with pheochromocytoma. The patient underwent a retroperitoneoscopic converted to open left adrenalectomy, splenectomy, and distal pancreatectomy because of severe inflammation in the retroperitoneum, probably from an adrenal or subcapsular renal hematoma secondary to systemic anticoagulation. Interval imaging before adrenalectomy for pheochromocytoma should be considered after thrombolysis and anticoagulation for ALI.

Acute limb ischemia (ALI) is a sudden decrease in limb perfusion that threatens limb viability. Using the Rutherford classification, limbs can be categorized as threatened but viable, or irreversibly damaged, which aids clinicians in selecting appropriate therapy. Treatment options for threatened limbs include catheter-directed thrombolysis, percutaneous mechanical thrombectomy, and surgical revascularization. Potential complications from ALI and treatment include ischemia-reperfusion injury, compartment syndrome, systemic inflammatory response syndrome, multiple organ dysfunction syndrome, hyperkalemia, and bleeding.

The present study aimed to clarify the current status, therapeutic strategy, and 1-year outcome in acute limb ischemia (ALI) patients in Japan. The EnDOvascular treatment (Edo) registry database includes 324 patients from 10 institutes who were registered between November 2011 and October 2013. A total of 70 ALI patients (mean age 74.0 years) from the Edo registry database were enrolled in this study. Of the 70 included patients, 72.9% were male and 35.7% had embolism. Of patients, 38.6%, 42.9%, and 18.6% underwent EVT, surgery, and hybrid thrombectomy, respectively, in primary revascularization strategy. Limb ischemia was categorized into four classes at initial evaluation: SVS/ISCVS class I (n = 13, 18.6%), SVS/ISCVS class IIa (n = 36, 51.4%), SVS/ISCVS class IIb (n = 21, 30%), and SVS/ISCVS class III (n = 0, 0%). Three patients with SVS/ISCVS class IIb limb ischemia developed myonephropathic metabolic syndrome. No catheter-directed thrombolysis was employed as a primary revascularization strategy. The 1-year rates of all-cause death, major amputation, and a composite of perioperative death or major adverse limb event were 28.6%, 5.7%, and 40.0%, respectively. Lower age, male sex, dyslipidemia, high estimated glomerular filtration rate, high albumin level, and low C-reactive protein level were independent positive predictors of all-cause death. In this registry, SVS/ISCVS class IIa ALI was predominant. Approximately 40% of primary revascularization strategy was surgery and EVT, followed by hybrid therapy. All-cause death and major amputation rates at 1 year were less than 30% and 6%, respectively.

Die periphere arterielle Verschlusskrankheit (pAVK) ist eine haufige Manifestation der Atherosklerose mit hohem Risiko fur kardiovaskulare Ereignisse. Als Screening nach einer pAVK dient die Messung des ABI („ankle-brachial index“). Man unterscheidet das stabile Stadium der Claudicatio intermittens vom Stadium der kritischen Extremitatenischamie (CLI „critical limb ischemia“). In der Therapie sind eine Nikotinkarenz sowie die lipidsenkende Therapie mit Statinen und einem Ziel-LDL(„low-density lipoprotein“)-Cholesterin von weniger als 55 mg/dl zentrale Elemente. Bei Patienten mit symptomatischer pAVK ist eine Thrombozytenaggregationshemmung indiziert. Neben Clopidogrel 75 mg oder Acetylsalicylsaure (ASS) 100 mg kann bei hohem Risiko auch eine Kombinationstherapie von ASS 100 mg und 2‑mal 2,5 mg Rivaroxaban zum Einsatz kommen. Bei kritischer Extremitatenischamie ist immer eine Revaskularisation (perkutane Intervention, Operation) zum Extremitatenerhalt indiziert. Bei Claudicatio intermittens ist das zentrale Element der Therapie ein Gehtraining, eine Revaskularisation kommt bei hohem Leidensdruck zum Einsatz.

ObjectivesSince nonvalvular atrial fibrillation is persistent in nature, patients with chronic nonvalvular atrial fibrillation are at life-time risk for development of thromboembolic events. Several novel oral anticoagulants have entered the market and there has been a growing body of evidence regarding their efficacy in prevention of ischemic stroke and arterial thromboembolism. The present study sought to compare the baseline characteristics between patients presenting with upper and lower extremity arterial thromboembolism developed secondary to nonvalvular atrial fibrillation.MethodsThis retrospective study was made up of patients presenting with acute upper or lower extremity arterial thromboembolism as the first presentation of atrial fibrillation. Patients were included if they had acute upper or lower critical limb ischemia symptoms lasting for less than one week. Patients in whom chronic peripheral artery disease was diagnosed were also excluded to prevent potential confounding.ResultsOverall, 46.9% of patients presented with upper extremity arterial thromboembolism and 53.1% of patients presented with lower extremity arterial thromboembolism. None of the baseline characteristics showed significant difference between patients with upper and lower extremity arterial thrombosis.ConclusionIt was observed that there was no significant difference in the incidence of extremity involvement of acute arterial thromboembolism occurring in patients with nonvalvular atrial fibrillation in our study, and we think that acute arterial thromboembolism must be taken into consideration as one of the first signs and symptoms of atrial fibrillation.

Aims In peripheral artery disease (PAD), endovascular treatment success of heavily calcified lesions is often compromised by a number of vascular complications, such as recoils, dissections and need for target vessel re-interventions. The increasing use of scoring balloon techniques has raised the hope for better periprocedural outcomes; however, the knowledge regarding the actual benefits of the scoring balloon technique in comparison to standard therapy is still limited. Thus, the aim of the current study was to determine the safety and effectiveness of scoring balloon angioplasty in a real-life patients’ collective with PAD. Methods and Results A total of 425 patients with moderate to severely calcified femoropopliteal lesions received interventional treatment between 2011 and 2018 at the single center; 230 received a treatment with a scoring balloon (AngioSculpt™), and 195 received a plain procedure without AngioSculpt™. Key questions of this analysis were: (1) whether AngioSculpt™ can be used as a safe and effective stand-alone treatment in heavily calcified lesions in a 24-month follow-up, as well as (2) whether target lesion preparation with scoring balloon bears additional benefits to standard treatment (PTA ± stent implantation). In terms of freedom from target lesion revascularization there were no significant differences between AngioSculpt™ and standard procedure (82.3% vs. 78.1%, P > 0.05). Vessel preparation with balloon angioplasty had no additional effects on survival and amputation rates in comparison to standard treatment without AngioSculpt™ (P > 0.05). The deployment of a scoring balloon did not reduce the subsequent need for additional stent implantations (32.6%, and 32.3%, P > 0.05). Conclusion Lesion preparation with AngioSculpt™ scoring balloon represents a safe and effective tool in the treatment of complex femoropopliteal lesions. In this retrospective analysis, AngioSculpt™ scoring balloon angioplasty did not significantly improve vessel patency- both when used as an adjunctive in preparation for stenting and as stand-alone treatment. A prospective study is needed to further investigate the scoring balloon treatment options. Graphic abstract

The left internal mammary artery (LIMA) is the gold standard conduit used to revascularize the left anterior descending artery and has consistently been shown to be associated with better survival, graft patency, and freedom from cardiac events compared with other used conduits. Evaluation of LIMA flow and anatomy is not routinely done by the interventional cardiologist while performing the left heart catheterization. We present a case where the LIMA was found to be the major blood supply to the left leg, which might have led to leg ischemia if the LIMA had been used as graft.

Objective COVID-19 infection results in a hypercoagulable state predisposing patients to thrombotic events. We report the 3- and 6- month follow-up of 27 patients who experienced acute arterial thrombotic events in the setting of COVID-19 infection. Methods Data was prospectively collected and maintained for all vascular surgery consultations in the Mount Sinai Health System from patients who presented between March 16th and May 5th, 2020. Results 27 patients experienced arterial thrombotic events. Average length of stay was 13.3 ± 15.4 days. 14 patients were treated with open surgical intervention, 6 were treated with endovascular intervention, and 7 were treated with anticoagulation only. At 3-month follow-up, 11 patients (40.7%) were deceased. 9 patients who expired did so during the initial hospital stay. The 3-month cumulative primary patency rate for all interventions was 72.2%, and the 3-month primary patency rates for open surgical and endovascular interventions were 66.7 and 83.3 respectively. There were 9 (33.3%) readmissions within 3 months. 6-month follow-up was available in 25 (92.6%) patients. At 6-month follow-up, 12 (48.0%) patients were deceased, and the cumulative primary patency rate was 61.9%. The 6-month primary patency rates of open surgical and endovascular interventions were 66.7% and 55.6% respectively. The limb-salvage rate at both 3- and 6-months was 89.2%. Conclusion Patients with COVID-19 infections who experienced thrombotic events saw high complication and mortality rates with relatively low patency rates.

Introduction: In this study, we determined the influence of intrinsic exercise capacity on the vascular adaptive responses to hind limb ischemia. High Capacity Running, HCR; Low Capacity Running, LCR, rats were used to assess intrinsic aerobic capacity effects on adaptive responses to ischemia.Methods: Muscle samples from both ischemic and non-ischemic limb in both strains were compared, histologically for the muscle-capillary relationship, and functionally using microspheres to track blood flow and muscle stimulation to test fatigability. PCR was used to identify the differences in gene expression between the phenotypes following occlusive ischemia.Results: Prior to ligation, there were not significant differences between the phenotypes in the exhaustion time with high frequency pacing. Following ligation, LCR decreased significantly in the exhaustion time compare with HCRs (437 ± 47 vs. 824 ± 56, p < 0.001). The immediate decrease in flow was significantly more severe in LCRs than HCRs (52.5 vs. 37.8%, p < 0.001). VEGF, eNOS, and ANG2 (but not ANG1) gene expression were decreased in LCRs vs. HCRs before occlusion, and increased significantly in LCRs 14D after occlusion, but not in HCRs. LCR capillary density (CD) was significantly lower at all time points after occlusion (LCR 7D = 564.76 ± 40.5, LCR 14D = 507.48 ± 54.2, both p < 0.05 vs. HCR for respective time point). NCAF increased significantly in HCR and LCR in response to ischemia.Summary: These results suggest that LCR confers increased risk for ischemic injury and is subject to delayed and less effective adaptive response to ischemic stress.

Background Spread of coronavirus has led to the coronavirus disease (COVID-19) pandemic and resulting in new challenges. COVID-19 can cause thrombotic complications such as acute limb ischemia (ALI). This complication may increase the risk of morbidity and mortality in COVID-19 patient. A high index of suspicion should be maintained for ALI in COVID-19 patient, which is a vascular emergency. Case Description A-53 year old male presented to the emergency department with acute left leg pain and shortness of breath since two days before admission. Physical examination revealed heart rate of 120x/min, blood pressure 130/100 mmHg, and oxygen saturation 96%. The patient had bilateral crackles on lung auscultation and absent left dorsalis pedis pulse. His left foot was discoloured, cold to the touch, and mottled in appearance. He had elevated D-dimer. Chest x-ray showed bilateral hazy infiltrates. COVID-19 was diagnosed on the basis of RT-PCR testing. He received antibiotic, antiviral, and enoxaparin. Unfortunately, he underwent amputation procedure. Discussion COVID-19 has been associated with systemic effects resulting in cardiovascular, hematologic, neurologic, immunologic, and renal complications. Arterial thrombosis is an important consideration in COVID-19 patient associated with systemic inflammatory response, hypercoagulable states, and endothelial injury. ALI can occur during in-hospital evolution of COVID-19 infection or they can be admitted to the hospital for this vascular condition with mild or no respiratory symptoms. Some patients are able to achieve revascularization with observation or medical and/or surgical intervention, but other patients succumb to either amputation or death.

Introduction The main goal of this systematic review is to analyze the outcomes of acute limb ischemia (ALI) in patients suffering from the novel Coronavirus COVID-19 (Sars-Cov-2). Evidence of acquisition A systematic review on MEDLINE and Embase was conducted up to May 15, 2021. All papers were sorted by abstract and full text by two independent authors. Systematic reviews, commentaries, and studies that did not distinguish status of COVID-19 infection were excluded from review. Patient demographics were recorded along with modality of treatment (endovascular and/or surgical). We analyzed 30-day outcomes, including mortality. Primary outcome was to evaluate clinical characteristic of ALI in patients affected by SARS-CoV-2 in term of location of ischemia, treatment options and 30-day outcomes. Evindence synthesis We selected 36 articles with a total of 194 patients. The majority of patients were male (80%) with a median age of 60 years old. The treatment most used was thromboembolectomy (31% of all surgical interventions). A total of 32 patients (19%) were not submitted to revascularization due to critical status. The rate of technical success was low (68%) and mortality rate was high (35%). Conclusions This review confirms that Sars-Cov-2 is associated with a high risk of ALI. Further studies are needed to investigate the association and elucidate potential mechanisms, which may include a hypercoagulable state and hyperactivation of the immune response. Furthermore, management of ALI is not standardized and depends on patient's condition and extension of the thrombosed segment. ALI in COVID-19 patients is associated with high risk of failure of revascularization and perioperative mortality.

The novel pandemic of coronavirus infection (COVID-19) has been linked with coagulopathy and thromboembolic events, causing limb loss and finally death. The present report describes a case of upper limb ischemia in a patient with COVID-19 infection, who lacked conventional risk factors for acute limb ischemia (ALI).mAn 83 year-old man with intraluminal thrombus and the occlusion of the axillary and brachial arteries, ceasing blood supply to the distal part of the body, was tested positive for the COVID-19 infection. The patient received therapeutic anticoagulation and underwent open thromboembolectomy, which failed to save the patient's life. The link between COVID-19 and thromboembolism remains unknown and needs further studies to be disclosed.

Acute limb ischemia of the upper extremity is less frequently encountered than in the lower extremity. The etiology is typically cardioembolic. Axillary-femoral stump syndrome is a rare complication associated with an occluded axillary-femoral bypass graft. We present the case of recurrent acute limb ischemia of the upper extremity whose embolic source was a retained cuff of a previously explanted axillary-profunda bypass graft. The patient failed anticoagulation after an initial embolectomy and after a recurrent embolism from the retained cuff, ultimately required cuff exclusion with a covered stent.

Cardiac myxomas are the most common benign cardiac tumors in adults that can present with peripheral embolization. Complete detachments of myxomas are rare and tend to cause aortoiliac embolism. We report a case of a middle-aged woman with bilateral popliteal artery and segmental renal artery embolisms secondary to a completely detached cardiac myxoma. This case highlights cardiac myxomas as an important cause of acute limb ischemia and that it is not excluded by a normal echocardiogram result.

Objective The purpose of this study was to examine the efficacy and safety of catheter-directed thrombolysis (CDT) for first-line treatment of popliteal and infrapopliteal acute limb ischemia. Methods A total of 28 consecutive patients (30 limbs) who underwent CDT for treatment of popliteal and infrapopliteal acute limb ischemia of thromboembolic origin between March 2012 and December 2017 were enrolled in this study. Per the Society for Vascular Surgery, limbs were classified into three runoff score groups: 10, poor. The primary end points were primary patency and limb salvage assessed by Kaplan-Meier survival analysis. Secondary end points were technical success and clinical success. The Society for Vascular Surgery-recommended scale for gauging changes in clinical status was used to assess clinical success. Safety of the procedure was evaluated on the basis of periprocedural complications according to the Society of Interventional Radiology classification system. Results Technical success was achieved in 25 (83.33%) treated limbs. Improved clinical status (grade +3/+2) was achieved in 93.33% of limbs. Primary patency and limb salvage for the entire cohort were 76.67% and 90% at 6 months and 60.0% and 76.67% at 12 months, respectively. The patency rate at 6 months and 12 months was 91.67% and 83.33% for the good runoff group, 80% and 60% for the compromised runoff group, and 50% and 25% for the poor runoff group, respectively. The patency rate of the good runoff group was significantly higher compared with that of the poor runoff group (P = .004). Major amputation rate and mortality rate were 16.67% and 7.14%, respectively, at 12 months. The reintervention rate was 3.57% at 6 months and 21.42% at 12 months. Conclusions CDT is safe and effective for revascularization of smaller vessel acute arterial thromboembolism as a primary therapy. However, more studies with a larger sample are warranted.

A 64-year-old woman came to our hospital because of intermittent claudication of her left leg. She had undergone meniscectomy of the left knee in her 30s. The ankle-brachial pressure index of the left leg was 0.70. Imaging examinations showed occlusion of the popliteal artery compressed by an enlarged sesamoid bone with osteophytes. No anatomic abnormalities of vessels and muscles were seen. A particular type of popliteal entrapment syndrome was diagnosed. After resection of the sesamoid bone, thromboendarterectomy and patch plasty were performed. After the operation, the claudication was improved, and the ankle-brachial pressure index of the left leg increased to 0.91. Keywords: Popliteal artery, Entrapment, PES, Limb ischemia, Sesamoid

Patients with persistent sciatic artery are at high risk for development of limb ischemia, aneurysm formation, and embolism. In this report, we identify a nonclassified left leg persistent sciatic artery in a patient with chronic limb ischemia. Vascular reconstruction was carried out by common iliac-deep femoral artery bypass to restore adequate arterial flow. Our approach to placement of the distal anastomosis on the deep femoral artery instead of on the popliteal artery, which is used in routine practice, may potentially increase treatment efficacy and decrease surgical complications. At 2-year follow-up, the patient remained asymptomatic and in good health. Keywords: Persistent sciatic artery (PSA), Bypass, Patency

Background: Acute limb ischemia (ALI) is an important clinical event and an emerging cardiovascular clinical trial outcome. Risk factors for and outcomes after ALI have not been fully evaluated. Methods: EUCLID (Examining Use of Ticagrelor in Peripheral Artery Disease) randomized patients with peripheral artery disease to ticagrelor versus clopidogrel. Enrollment criteria included an ankle-brachial index ≤0.80 or previous lower extremity revascularization. Patients were grouped according to the primary outcome, postrandomization ALI hospitalization. Baseline factors associated with ALI were identified using Cox proportional hazards modeling. Models with ALI hospitalization as a time-dependent covariate were developed for secondary outcomes of major adverse cardiovascular events (myocardial infarction, cardiovascular death, ischemic stroke), all-cause mortality, and major amputation. Results: Among 13 885 patients, 1.7% (n=232) had 293 ALI hospitalizations (0.8 per 100 patient-years). Patients with versus without ALI were younger and more often had previous peripheral revascularization and lower baseline ankle-brachial index. Treatment during ALI hospitalization included endovascular revascularization (39.2%, n=115), surgical bypass (24.6%, n=72), and major amputation (13.0%, n=38). After multivariable adjustment, any previous peripheral revascularization (Hazard Ratio [HR] 4.7, 95% CI 3.3–6.8, P P =0.03), and baseline ankle-brachial index ≤0.60 (HR 1.3 per 0.10 decrease, 95% CI 1.1–1.5, P P =0.02) and baseline statin use (HR 0.7, 95% CI 0.5–0.9, P P =0.04), all-cause mortality (adjusted HR 3.3, 95% CI 2.4–4.6, P P Conclusions: Previous peripheral revascularization, baseline atrial fibrillation, and lower ankle-brachial index identify peripheral artery disease patients at heightened risk for ALI, an event associated with subsequent cardiovascular and limb-related morbidity and mortality. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01732822.