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Kristofer M Charltonouw - One of the best experts on this subject based on the ideXlab platform.

  • management of Limb Ischemia in acute proximal aortic dissection
    Journal of Vascular Surgery, 2013
    Co-Authors: Kristofer M Charltonouw, Kaji Sritharan, Samuel S Leake, Harleen K Sandhu, Charles C Miller, Ali Azizzadeh, Hazim J Safi
    Abstract:

    Background Management of Limb and other malperfusion syndromes is controversial in acute type A aortic dissection. We assessed our hypothesis that urgent proximal aortic repair resolves most cases of Limb Ischemia without additional peripheral revascularization. Methods We retrospectively reviewed operative cases of acute type A aortic dissection from 1999 to 2011. Our standard technique involved urgent replacement of the ascending aorta and hemiarch. Persistent Limb Ischemia after aortic repair was treated by bypass surgery. Comparisons between groups both with and without Limb Ischemia were made. Results We repaired 335 cases during the study period. Sixty-one patients had Limb Ischemia (18.2%), of whom 51 were classified with lower Limb Ischemia (15.2%). All patients with upper Limb Ischemia survived to discharge without Limb loss or death. Only 11 of the 51 patients with lower Limb Ischemia (21.6%) required peripheral revascularization after aortic repair. There was one case of lower Limb loss resulting from delayed recognition of persistent Ischemia. Renal dysfunction occurred in 21% of patients with isolated lower Limb Ischemia and in 31% of patients with uncomplicated dissection ( P  = .29). In-hospital mortality was 13.7% overall and 8.0% in patients with isolated lower Limb Ischemia ( P  = .89). There was no difference in long-term survival between isolated Limb Ischemia and uncomplicated cases ( P  = .54). Conclusions Most cases of Limb Ischemia resolve after immediate repair of acute type A aortic dissection. There is no difference in renal dysfunction or in-hospital or long-term mortality between patients with isolated Limb Ischemia and those with nonmalperfusion dissection. If Ischemia persists, Limb salvage is successful if revascularization is expeditious.

Andres Schanzer - One of the best experts on this subject based on the ideXlab platform.

  • outcomes of lower extremity bypass performed for acute Limb Ischemia
    Journal of Vascular Surgery, 2013
    Co-Authors: Donald T Baril, Virendra I Patel, Dejah R Judelson, Philip P Goodney, James T Mcphee, Nathanael D Hevelone, Jack L Cronenwett, Andres Schanzer
    Abstract:

    Objective Acute Limb Ischemia remains one of the most challenging emergencies in vascular surgery. Historically, outcomes following interventions for acute Limb Ischemia have been associated with high rates of morbidity and mortality. The purpose of this study was to determine contemporary outcomes following lower extremity bypass performed for acute Limb Ischemia. Methods All patients undergoing infrainguinal lower extremity bypass between 2003 and 2011 within hospitals comprising the Vascular Study Group of New England were identified. Patients were stratified according to whether or not the indication for lower extremity bypass was acute Limb Ischemia. Primary end points included bypass graft occlusion, major amputation, and mortality at 1 year postoperatively as determined by Kaplan-Meier life table analysis. Multivariable Cox proportional hazards models were constructed to evaluate independent predictors of mortality and major amputation at 1 year. Results Of 5712 lower extremity bypass procedures, 323 (5.7%) were performed for acute Limb Ischemia. Patients undergoing lower extremity bypass for acute Limb Ischemia were similar in age (66 vs 67; P  = .084) and sex (68% male vs 69% male; P  = .617) compared with chronic Ischemia patients, but were less likely to be on aspirin (63% vs 75%; P P P P  = .004) or a prior ipsilateral percutaneous intervention (41% vs 29%; P  = .001). Bypasses performed for acute Limb Ischemia were longer in duration (270 vs 244 minutes; P  = .007), had greater blood loss (363 vs 272 mL; P P  = .003). Acute Limb Ischemia patients experienced increased in-hospital major adverse events (20% vs 12%; P P  = .77), but did have significantly higher rates of Limb loss (22.4% vs 9.7%; P P P  = .001) and mortality (hazard ratio, 1.41; confidence interval, 1.09-1.83; P  = .009) at 1 year. Conclusions Patients who present with acute Limb Ischemia represent a less medically optimized subgroup within the population of patients undergoing lower extremity bypass. These patients may be expected to have more complex operations followed by increased rates of perioperative adverse events. Additionally, despite equivalent graft patency rates, patients undergoing lower extremity bypass for acute Ischemia have significantly higher rates of major amputation and mortality at 1 year.

Frank P.h.a. Vandenbussche - One of the best experts on this subject based on the ideXlab platform.

  • On the pathogenesis of recipient twin Limb Ischemia.
    The Journal of Pediatrics, 2007
    Co-Authors: Enrico Lopriore, Frans J. Walther, Dick Oepkes, Frank P.h.a. Vandenbussche
    Abstract:

    To the Editor: We read with great interest the article on recipient twin Limb Ischemia (RTLI). However, we are concerned about several statements, in particular those concerning the pathogenesis of RTLI. Contrary to what is suggested in the report, perinatal Limb Ischemia in recipients with twin-to-twin transfusion syndrome (TTTS) has previously been recognized as a distinct entity. Several cases of RTLI have been reported, linking specifically recipient-status and Limb Ischemia. Although the pathogenesis of RTLI remains to be elucidated, several authors suggest an association between polycythemia and RTLI. These findings are in contrast to the lack of association with polycythemia reported by Broadbent. Several factors may explain this discrepancy. First, as correctly suggested by the author, Limb Ischemia in the 3 reported cases was probably caused by umbilical artery catheterization rather than the fact that these were (non-polycythemic) recipients. Second, of the other 6 cases of postnatal RTLI reported in the literature, severe polycythemia was present in 5. In the sixth case, hemoglobin or hematocrit values were not mentioned. Severe polycythemia can cause thrombosis and Limb Ischemia. Because recipient twins may have polycythemia at birth, this pathogenetic link between RTLI and polycythemia should not be disregarded. Other mechanisms such as paradoxically elevated angiotensin levels in recipients may also cause peripheral vasoconstriction and Ischemia. Broadbent does not mention whether RTLI in TTTS is a rare phenomenon or not. In our experience, the prevalence of Limb injury is extremely low. In a consecutive series of almost 200 cases of TTTS presented at our national fetal treatment center in recent years, we have encountered only 1 case of prenatal RTLI and no cases of postnatal RTLI. The treatment of choice for TTTS at our institution is fetoscopic laser surgery, whereas the 3 cases presented in the article were treated with amnioreduction. Amnioreduction is not a curative treatment and allows inter-twin blood transfusion to persist. Whether laser treatment reduces the prevalence of RTLI remains to be elucidated.

Hazim J Safi - One of the best experts on this subject based on the ideXlab platform.

  • management of Limb Ischemia in acute proximal aortic dissection
    Journal of Vascular Surgery, 2013
    Co-Authors: Kristofer M Charltonouw, Kaji Sritharan, Samuel S Leake, Harleen K Sandhu, Charles C Miller, Ali Azizzadeh, Hazim J Safi
    Abstract:

    Background Management of Limb and other malperfusion syndromes is controversial in acute type A aortic dissection. We assessed our hypothesis that urgent proximal aortic repair resolves most cases of Limb Ischemia without additional peripheral revascularization. Methods We retrospectively reviewed operative cases of acute type A aortic dissection from 1999 to 2011. Our standard technique involved urgent replacement of the ascending aorta and hemiarch. Persistent Limb Ischemia after aortic repair was treated by bypass surgery. Comparisons between groups both with and without Limb Ischemia were made. Results We repaired 335 cases during the study period. Sixty-one patients had Limb Ischemia (18.2%), of whom 51 were classified with lower Limb Ischemia (15.2%). All patients with upper Limb Ischemia survived to discharge without Limb loss or death. Only 11 of the 51 patients with lower Limb Ischemia (21.6%) required peripheral revascularization after aortic repair. There was one case of lower Limb loss resulting from delayed recognition of persistent Ischemia. Renal dysfunction occurred in 21% of patients with isolated lower Limb Ischemia and in 31% of patients with uncomplicated dissection ( P  = .29). In-hospital mortality was 13.7% overall and 8.0% in patients with isolated lower Limb Ischemia ( P  = .89). There was no difference in long-term survival between isolated Limb Ischemia and uncomplicated cases ( P  = .54). Conclusions Most cases of Limb Ischemia resolve after immediate repair of acute type A aortic dissection. There is no difference in renal dysfunction or in-hospital or long-term mortality between patients with isolated Limb Ischemia and those with nonmalperfusion dissection. If Ischemia persists, Limb salvage is successful if revascularization is expeditious.

Roland S. Broadbent - One of the best experts on this subject based on the ideXlab platform.