Tag Archives: Ischemia

The surgical management and outcomes of dialysis access-associated steal syndrome (DASS)

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Al Shakarchi J, et al. Surgical techniques for haemodialysis access-induced distal ischaemia. J Vasc Access. 2016 Jan-Feb;17(1):40-6.

Results: Following strict inclusion/exclusion criteria by two reviewers, twenty-seven studies of surgical interventions were included and divided into subgroups for banding, DRIL, PAI and RUDI procedures. Both DRIL and banding procedures were found to have high rates of symptomatic relief. In addition, the DRIL has a significantly lower rate of early thrombosis than banding although the more recent papers seem to suggest that early thrombosis is less of a problem in banding. PAI and RUDI showed some promise but there were too few studies to be able to make any clear conclusions.

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Phlegmasia alba dolens and phlegmasia cerulea dolens

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Shackford SR. (2018). Venous Disease. In: Abernathy’s Surgical Secrets, 7th ed.: p. 357.

What is the difference between phlegmasia alba dolens and phlegmasia cerulea dolens? 

“These two entities occur following iliofemoral venous thrombosis, 75% of which occur on the left side presumably because of compression of the left common iliac vein by the overlying right common iliac artery (May-Thurner syndrome). Iliofemoral venous thrombosis is characterized by unilateral pain and edema of an entire lower extremity, discoloration, and groin tenderness. In phlegmasia alba dolens (literally, painful white swelling), the leg becomes pale. Arterial pulses remain normal. Progressive thrombosis may occur with propagation proximally or distally and into neighboring tributaries. The entire leg becomes both edematous and mottled or cyanotic. This stage is called phlegmasia cerulea dolens (literally, painful purple swelling). When venous outflow is seriously impeded, arterial inflow may be reduced secondarily by as much as 30%. Limb loss is a serious concern and aggressive management (i.e., venous thrombectomy, catheter-directed lytic therapy, or both) is necessary.”

Chinsakchai K, et al. Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 2011 Jan;45(1):5-14. Full-text for Emory users.

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Acute limb ischemia and antithrombotic therapy in COVID-19 patients

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Galyfos G, et al. Acute limb ischemia among patients with COVID-19 infection. J Vasc Surg. 2022 Jan;75(1):326-342. doi: 10.1016/j.jvs.2021.07.222. Epub 2021 Aug 12.

Results: In total, 34 studies (19 case reports and 15 case series/cohort studies) including a total of 540 patients (199 patients were eligible for analysis) were evaluated. All studies were published in 2020. Mean age of patients was 61.6 years (range, 39-84 years; data from 32 studies) and 78.4% of patients were of male gender (data from 32 studies). There was a low incidence of comorbidities: arterial hypertension, 49% (29 studies); diabetes mellitus, 29.6% (29 studies); dyslipidemia, 20.5% (27 studies); chronic obstructive pulmonary disease, 8.5% (26 studies); coronary disease, 8.3% (26 studies); and chronic renal disease, 7.6% (28 studies). Medical treatment was selected as first-line treatment for 41.8% of cases. Pooled mortality rate among 34 studies reached 31.4% (95% confidence interval [CI], 25.4%%-37.7%). Pooled amputation rate among 34 studies reached 23.2% (95% CI, 17.3%-29.7%). Pooled clinical improvement rate among 28 studies reached 66.6% (95% CI, 55.4%%-76.9%). Pooled reoperation rate among 29 studies reached 10.5% (95% CI, 5.7%%-16.7%). Medical treatment was associated with a higher death risk compared with any intervention (odds ratio, 4.04; 95% CI, 1.075-15.197; P = .045) although amputation risk was not different between the two strategies (odds ratio, 0.977; 95% CI, 0.070-13.600; P = .986) (data from 31 studies).

Conclusions: SARS-CoV-2 infection is associated with a high risk for thrombotic complications, including ALI. COVID-associated ALI presents in patients with a low incidence of comorbidities, and it is associated with a high mortality and amputation risk. Conservative treatment seems to have a higher mortality risk compared with any intervention, although amputation risk is similar.

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Bypass versus Angioplasty in Severe Ischaemia of the Leg

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Bradbury AW, Adam DJ, Bell J, et al.; BASIL trial Participants. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: An intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg. 2010 May;51(5 Suppl):5S-17S.

Free full-text.

Summary of BASIL trial recommendations: The BASIL trial suggests that those SLI patients who are likely to live ≥2 years are probably better served by a BSX-first strategy, preferably with vein. [37] Those SLI patients who are unlikely to live 2 years, and possibly those in whom vein is not available for bypass, are probably better served by a BAP-first strategy because they are unlikely to survive to reap the longer-term benefits of surgery, they may be more likely to suffer surgical morbidity and mortality, and because angioplasty is significantly less expensive than surgery in the short-term.

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Open vs endovascular revascularization for acute limb ischemia: a review of major trials

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One discussion this week involved open surgical versus endovascular revascularization for acute limb ischemia (ALI).

Reference: Wang JC, Kim AH, Kashyap VS. Open surgical or endovascular revascularization for acute limb ischemia. Journal of Vascular Surgery. 2016 Jan;63(1):270-278. doi:10/1016/j.jvs.2015.09.055.

Summary: Peripheral arterial disease affects approximately 10 million Americans. It can lead to lower extremity ischemic rest pain or tissue loss (Rutherford classification 4 to 6, or Fontaine classification III and IV). Acute limb ischemia (ALI) is defined as the presence of symptoms within 2 weeks of onset. ALI pathogenesis includes vascular stenoses with subsequent in situ thrombosis or thromboembolism from a cardiac or aortoiliac source. Stenotic lesions may indicate untreated comorbidities (eg, hypertension, hypercholesterolemia, diabetes, or tobacco use), whereas thromboembolisms implicate undiagnosed cardiac arrhythmias, myocardial infarction (MI), or mural thrombus. Limb loss risk due to ALI can be as high as 40% with an attendant mortality rate of 15% to 20% (p.270).

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