Hani Slim

The impact of arterial pedal arch quality and angiosome revascularization on foot tissue loss healing and infrapopliteal bypass outcome

OBJECTIVE This study evaluated the effect of pedal arch quality on the amputation-free survival and patency rates of distal bypass grafts and its direct impact on the rate of healing and time to healing of tissue loss after direct angiosome revascularization in patients with critical limb ischemia (CLI). METHODS Between 2004 and 2011, patients undergoing distal bypass for CLI (Rutherford 4-6) were divided in groups taking into consideration the state of the pedal arch and direct angiosome revascularization (DAR) and non-DAR. Angiography was used to divide the pedal arch into three groups: complete pedal arch (CPA), incomplete pedal arch (IPA), and no pedal arch (NPA). The primary end points were patency rates at 12 months, amputation-free survival at 48 months, and the rate of healing and time to healing of foot tissue loss. RESULTS A total of 154 patients (75% men) with CLI underwent 167 infrapopliteal bypasses. Patients were a median age of 75 years (range, 46-96 years). Diabetic mellitus was present in 76%, chronic renal failure in 28%, and ischemic heart disease in 44%. The primary patency rates at 1 year in the CPA, IPA, and NPA groups were 58.4%, 54.6%, and 63.8%, respectively (P = .5168), the secondary patency rates were 86.0%, 84.7%, and 88.8%, respectively (P = .8940), and the amputation-free survival at 48 months was 67.2%, 69.7%, and 45.9%, respectively (P = .3883). Tissue loss was present in 141 of the 167 bypasses. In the CPA group, 83% of tissue loss with DAR healed compared with 92% in the non-DAR (median time to healing, 66 vs 74 days). Similarly in the IPA group, 90% with DAR healed compared with 81% in the non-DAR (median time to healing, 96 vs 86 days). In the NPA group, only 75% with DAR healed compared with 73% in the non-DAR (median time to healing, 90 vs 135 days). There was a significant difference in healing and time to healing between the CPA/IPA and NPA groups (P = .0264). CONCLUSIONS The quality of the pedal arch did not influence the patency or the amputation-free survival rates. However, the rates for healing and time to healing were directly influenced by the quality of the pedal arch rather than the angiosome revascularized.

The role of cerebral oximetry in combination with awake testing in patients undergoing carotid endarterectomy under local anaesthesia.

INTRODUCTION The aim of this study is to analyse the role of cerebral oximetry in combination with awake testing in detecting cerebral ischaemia in patients undergoing carotid endarterectomy (CEA) under local anaesthesia (LA). METHODS One hundred consecutive patients scheduled for CEA under LA were investigated. Regional oxygen saturation (rSO(2)) was measured with a cerebral oximeter. Cerebral ischaemia was assessed by awake testing in conjunction with rSO(2). Shunting was based solely on deterioration in conscious state assessed by awake testing. The correlation between awake testing and percentage fall in rSO(2) levels was statistically analysed. RESULTS Patients requiring general anaesthesia were excluded from analysis (n = 17). Seven patients developed deterioration in conscious state and an immediate drop in rSO(2) ≥20% following carotid cross-clamping. Two patients requiring shunting for non-neurological reasons were excluded from analysis. Two patients had a drop in rSO(2) ≥20%, but remained conscious and were not shunted. There were no permanent neurological deficits postoperatively. Statistical analysis showed a sensitivity of 100% with a specificity of 96% yielding a positive predictive value of 81% and negative predictive value of 100% for a ≥19% drop in rSO(2). CONCLUSION Cerebral oximetry using a cut off ≥19% drop in rSO(2) has a high sensitivity and specificity when compared with awake testing.

Distal versus Ultradistal Bypass Grafts: Amputation-free Survival and Patency Rates in Patients with Critical Leg Ischaemia

OBJECTIVES Compare the outcome of distal (bypass to the crural arteries) versus ultradistal (bypass to the pedal arteries) bypasses in patients with critical leg ischaemia (CLI). DESIGN Retrospective analysis of prospectively collected data of patients with CLI undergoing infra-popliteal bypass surgery is performed. MATERIALS AND METHODS Patients undergoing infra-popliteal bypass at a single institution between 2004 and 2010 are included. Patency rates at 1-year and amputation-free survival at 12 and 48 months are analysed. RESULTS Two hundred and thirty bypasses were performed in 209 consecutive patients (156 men, median age; 76 years, range; 19-96 years). One hundred and seventy nine (78%) bypass were classified as distal and 51 (22%) as ultradistal. The incidence of diabetes mellitus was significantly higher in the ultradistal group (p=0.0025). At 1-year, the distal group primary, assisted-primary and secondary patency rates were 61.7%, 83.1% and 87.4% compared to 61.9%, 87.4% and 87.4% in the ultradistal group respectively. Amputation-free survival at 12 and 48 months was 82.9% and 61.5% in the distal group compared to 83.0% and 64.9% in the ultradistal group. CONCLUSIONS This study show that both distal and ultradistal bypass have comparable outcome regardless of the co-morbidities. The authors believe that elderly patients should be offered ultradistal bypass if indicated to avoid major amputation.

Outcome of infra-inguinal bypass grafts using vein conduit with less than 3 millimeters diameter in critical leg ischemia

OBJECTIVE The purpose of this study was to evaluate the difference in amputation-free survival and patency rates of infra-inguinal bypass grafts in patients with critical leg ischemia (CLI) with vein conduits with an internal diameter <3 mm compared to those with vein conduits with a diameter of ≥ 3 mm. METHODS Retrospective analysis of all consecutive patients with CLI undergoing infra-inguinal bypass. Preoperative duplex scan mapping and measurement of potential vein grafts were performed on all patients. Patients were recruited in a 1-year duplex scan graft surveillance program. Primary end points were amputation-free survival and patency rates at 1 year postoperatively. Kaplan-Meier and χ(2) test were used for statistical analysis. RESULTS Between January 2004 and April 2010, 157 consecutive patients with CLI underwent 171 bypasses using vein conduits (111 men, 46 women; median age, 75 years; range, 45-96 years). Ninety-three bypasses (54.4%) were performed for tissue loss, 44 (25.7%) for gangrene, and for rest pain. Of the 157 patients, 113 (72.0%) had diabetes mellitus, 40 (25.5%) had renal impairment, 131 (83.4%) had hypertension, and 64 (40.8%) had ischemic heart disease. Femoro-popliteal bypass was performed in 38 cases (22.2%), whereas 133 (77.8%) of the bypasses were femoro-distal. Autogenous great saphenous vein (GSV) was used in all cases. All grafts were reversed. The diameter of 31 (18%) vein conduits measured <3 mm (range, 2-2.9 mm) on preoperative duplex scan. One hundred thirty-four grafts had at least 1-year follow-up. The primary, assisted primary, and secondary patency rates at 1 year for vein conduits <3 mm were 51.2%, 82.6%, and 82.6%, respectively, compared to 68.4%, 93.3%, and 95.2%, respectively, in the ≥ 3 mm group. This was only significant for the secondary patency (P = .0392). The amputation-free survival at 48 months was 70.8% for vein conduits <3 mm and 57.3 for vein conduits ≥ 3 mm. CONCLUSION This series has shown that primary and assisted primary patency rates in small veins are not significantly different at 1 year but the secondary patency rates are better in the larger veins. Similarly, the amputation-free survival was also comparable. The authors would, therefore, advocate the use of small veins >2 mm in diameter in patients with CLI. Duplex scan surveillance followed by early salvage angioplasty for threatened grafts is needed to achieve good patency rates in both groups.

A Noval Approach Using Angioplasty for Recanalization of a Chronically Occluded Bypass Vein Graft for Limb Salvage

Background: Reporting a noval approach for recanalization of a chronically occluded bypass using balloon angioplasty. Methods: A chronically occluded distal bypass graft was managed successfully with balloon angioplasty in a diabetic patient with critically ischemic leg. Results: Successful recanalization of the chronically occluded distal bypass graft. Surveillance duplex scans up to 10 months revealed the graft to be patent with pulsatile flow. Patient fully healed. Conclusion: Balloon angioplasty of a chronically occluded distal bypass is feasible.

Importance of Pedal Arch in Treatment of Critical Limb Ischaemia

The revascularization of patients with critical leg ischaemia (CLI) is essential for limb salvage and healing tissue loss. Both infrainguinal bypass surgery and angioplasty are established techniques in the treatment of these patients. The healing of tissue loss is dependent on several factors, but re-establishing direct blood flow is mandatory to achieve this process. The role of the pedal arch in the treatment of patients with CLI has not been fully studied. The quality of the pedal arch could impact on the ability of a successful revascularization in healing tissue loss, as well as the long-term durability of both surgical and radiological treatment of patients with CLI.

Recanalisation of Chronically Occluded Remote Superficial Femoral Artery Endarterectomy Through Angioplasty for Limb Salvage

We report a novel application of balloon angioplasty to recanalise a chronically occluded remote endarterectomy superficial femoral artery. This patient previously had two occluded surgical bypass grafts in an attempt to revascularise the limb and presented with critical limb ischaemia and necrotic foot ulcerations. Following the angioplasty, the patient showed significant improvement in rest pain and healing of the ulcerations. This technique may be useful for limb salvage in patients where surgical options have been exhausted.

Outcome of Lower Limb Distal Bypass in Afro-Caribbean Populations

There is little data on outcome following lower limb bypass surgery in ethnic minorities in the United Kingdom. We looked at the results of distal bypass surgery in Afro-Caribbeans (AFCs) and compared it to caucasians (CAs). Patients undergoing distal bypass between 2004 and 2009 were analyzed. Life table analyses and log rank were used to compare graft patency and amputation-free survival. A total of 86 CA and 39 AFC patients, with a median age of 78 years and 73 years, respectively (P = .01), underwent bypass. There were more women in AFC groups (41.1%) compared to CA group (19.2%, P = .01). Tissue loss as indication for surgery was more in AFC than in CA group (92.3% vs73.9%, P = .03). Primary, primary-assisted and secondary patency rates, and amputation-free survival at 12 months for AFCs compared to CAs (51.3 vs 44.6; 85.2 vs 80.9; 91.2 vs 84.4; and 84.9 vs 75.1). Graft patency after lower limb distal revascularization in AFCs is comparable to CAs.