Abstract
Background: Acute lower extremity limb ischemia (ALI) is a common vascular surgery emergency, primarily caused by embolism or atherosclerotic in situ thrombosis–acute on chronic limb ischemia (AoCLI). This study aimed to examine the clinical features and treatment challenges of AoCLI.
Methods and Results: Between January 2014 and December 2022, 73 patients with AoCLI (n=35) or embolic ALI (n=38) were analyzed. The time from ALI onset was significantly longer (P<0.01), and the rate of contralateral diseases was higher in AoCLI than embolic ALI (P<0.01). Treatment and intraoperative findings showed higher rates of failed thrombectomy (P=0.027), difficulty in crossing lesions (P<0.01), defined as failure of Fogarty catheter crossing despite guidewire navigation and requirement of the balloon angioplasty for the lesions, additional revascularization (P<0.01), and multi-segment treatment (P<0.01) in AoCLI. In multivariate analysis, unfavorable factors for endovascular therapy (EVT) were >2.5 days from ALI onset (odds ratio [OR] 1.4; 95% confidence interval [CI] 1.0–2.0), non-atrial fibrillation (OR 4.2; 95% CI 1.0–16.7), and collateral development (OR 9.0; 95% CI 1.0–81.5). Rates of failed EVT were 0% for no factors, 18% for 1 factor, 43% for 2 factors, and 90% for 3 factors.
Conclusions: AoCLI had more complex and multi-segment arterial lesions, making limb perfusion restoration difficult. The unfavorable factors for EVT could help stratify the optimal treatment of ALI in emergency settings.
Acute lower extremity limb ischemia (ALI) is a common vascular surgery emergency associated with high rates of morbidity and mortality.1 The most common causes of ALI are embolism, atherosclerotic in situ thrombosis, which is known as acute on chronic limb ischemia (AoCLI), thrombosis of previous revascularized vessels or grafts, peripheral arterial aneurysm, dissection, and traumatic arterial injury.2 Howard et al. demonstrated the pathogenesis of ALI other than traumatic or iatrogenic was 46.2% for embolic, 23.7% for AoCLI, 20.4% for multifactorial, and 9.7% for occluded stent-graft or occluded graft.3 Recently, a large cohort in the United States demonstrated that ALI incidence peaked in 2006 (7.16/100,000 person-years) but has declined since 2015 to 4.16/100,000 person-years in 2020 because of endovascular treatment (EVT), anticoagulants and increased insurance coverage.4 Therefore, it can be concluded that medications, including anticoagulants, can decrease embolic ALI. Based on these backgrounds, acute thrombosis in pre-existing diseased arteries, AoCLI, could be the main cause of ALI. AoCLI occurs when chronic stenotic lesions in occlusive atherosclerosis cause acute obstruction as a result of plaque rupture, hypovolemic state, or a hypercoagulable state, excluding traumatic injury.5 Traumatic injury also sometimes occurs thrombosis because of intimal injury or dissection, but is not included as AoCLI, because the guidelines on ALI considered its treatment separately from embolic ALI or AoCLI.3 The pathophysiology may be less severe because there may be sufficient collaterals, but revascularization is generally more challenging than ALI due to embolism, consideration of endovascular device choice and tools for the diseased vessels, potential vessel injury, incomplete revascularization, and the need for correction of the underlying vascular lesions in addition to thrombectomy.6 However, there are few reports showing what treatment is appropriate or outcomes for AoCLI. The aim of this study was to examine the clinical features and treatment challenges for AoCLI by making a comparison with embolic ALI.
Methods
This study was approved by the research ethics committee of Asahikawa Medical University (Reference no. 24097). The study design was a single-center, observational, and retrospective cohort study. From January 2014 to December 2022, 140 patients who presented with ALI at Asahikawa Medical University Hospital were included in a dedicated database. The following pathologies, which had different underlying mechanisms and treatment considerations, were excluded to ensure the study focused on a more specific and homogeneous group of patients with ALI. Patients with ALI who had a history of ipsilateral bypass surgery (n=49) were excluded from this study, as the etiology in these cases was often graft occlusion. Additionally, patients with ALI due to aortic occlusion (n=5), iatrogenic injury (n=6), traumatic injury (n=3), peripheral arterial aneurysm (n=2), or other (n=2) were excluded. A total of 73 patients with ALI was analyzed. The database interrogation identified 2 groups of patients based on the etiology of ALI: the acute on chronic (AoC) group (n=35), and the embolic group (n=38; Figure 1A). Furthermore, the research patients were categorized based on the presence or absence of underlying lesions, and the clinical features and treatment of ALI were analyzed accordingly.
Etiology and Anatomical Complexity
The etiology of ALI was determined based on computed tomography angiography (CTA), intraoperative angiography, other examinations including electrocardiogram or echocardiography, history of present ALI, and comorbidities. Embolic ALI was identified by factors such as arrhythmias (including atrial fibrillation), aortic thrombi (including aortic aneurysms), valvular heart disease, or cancers. AoCLI was diagnosed using preoperative CTA or intraoperative angiogram, which demonstrated distal outflow arteries enhanced by existing collaterals (Figure 2A,B). Arteries below the abdominal aorta were divided into 4 segments: iliac, common femoral, femoropopliteal (FP), and infrapopliteal (IP). Multi-segment treatment, involving lesions in multiple segments, was also assessed (Figure 2C). Additionally, in the AoCLI group, the responsible arterial segments were determined by preoperative CTA, intraoperative angiogram, or intraoperative findings. In all cases, the presence of atherosclerotic lesions in the contralateral leg was determined based on preoperative or postoperative CTA.
Treatment
The primary treatment in this cohort was surgical thrombectomy using Fogarty’s balloon catheter. Catheter-directed thrombus aspiration was not applied due to the high efficacy of surgical thrombectomy. Mechanical thrombectomy devices were not approved in Japan during the study period. Additional revascularization was performed when the initial surgical thrombectomy did not restore adequate distal perfusion. The decision to proceed with additional revascularization was based on both imaging results and the operator’s judgment during the procedure. The categorization of additional revascularization was as follows: EVT after surgical thrombectomy was categorized as EVT; surgical revascularization after surgical thrombectomy was categorized as surgical revascularization; and the combination of EVT and surgical reconstruction after surgical thrombectomy was categorized as hybrid therapy (Figure 1B). Additionally, catheter-directed thrombolysis (CDT) using urokinase, also known as urokinase-type plasminogen activator, was performed to dissolve residual blood clots if thrombectomy did not remove all clots or to prevent the reformation of thrombus after thrombectomy. To assess the anatomical complexity of diseased arteries, the number of wires, sheaths, and catheters (excluding Fogarty’s balloon catheters), as well as devices such as balloons for angioplasty and stents used in procedures, were also analyzed.
Postoperative Management
As postoperative management of ALI, temporary hemodialysis was initiated for suspected myonephropathic metabolic syndrome (MNMS) due to increased serum potassium, lactate, or decreased serum pH. Fasciotomy was performed to prevent compartment syndrome when increased fascial compartment pressure was likely, based on physical examination. The fasciotomy wound was initially managed openly, followed by negative pressure wound therapy, and then closed by direct skin closure or skin grafting.
Definition
The time from ALI onset was defined as the period from onset to diagnosis at our hospital. Failed revascularization was when perfusion to the foot was not restored due to incomplete revascularization, often due to the patient’s unstable condition from comorbidities such as intraoperative ventricular tachycardia or terminal cancer. Failed thrombectomy was defined as no thrombosis removal or inability to track Fogarty’s balloon catheter through the thrombotic lesion. Difficulty in crossing lesions was noted when the Fogarty catheter couldn’t cross despite guidewire navigation, requiring balloon angioplasty.
Treatment favorability for FP and IP segment occlusions was assessed through multivariable analysis of patient backgrounds, clinical findings, and anatomical findings from CTA and angiography. The analysis compared the ‘Bypass Favor’ group – cases with failed thrombectomy, difficulty in crossing, persistent acute ischemia, conversion to bypass surgery, or major amputation immediately after EVT with thrombectomy – with the ‘EVT Favor’ group, which included all other cases.
Statistics
Statistical analyses were performed using SPSS version 27 (IBM, Chicago, IL, USA). Patient demographics, comorbidities, outcomes, treatment and intraoperative findings were compared between the 2 groups using Pearson χ2
or Fisher exact tests for discrete variables, and Mann-Whitney U test for continuous variables not normally distributed. To evaluate the cut-off value, a receiver operating characteristic (ROC) curve was generated to determine the optimal cut-off value between the 2 groups. The area under the curve (AUC) was reported with 95% confidence intervals (CI). A P value ≤0.05 was considered statistically significant. Variables exhibiting significance levels of <0.2 in the univariate analyses were assessed in the multivariate logistic regression analysis, and odds ratios (OR) and 95% CI were used to explore the independent determinants of outcomes.
Results
Clinical Feature of AoCLI
Patient demographics and comorbidities were similar between the 2 etiologies, except for differences in smoking history, atrial fibrillation, cancer prevalence, antiplatelet use, and antithrombotic agent intake. A longer time from ALI onset and the higher rates of underlying arterial disease, collateral development, and contralateral arterial disease were shown in the AoC group (P<0.01 for each), while Rutherford class and preoperative and postoperative creatine kinase levels were not significant (Table 1).
Table 1.
Patient Background, Revascularization Outcomes, and Postoperative Management, Comparing the AoC Group With the Embolic Group
| Variable |
AoC
(n=35) |
Embolic
(n=38) |
P value |
| Background |
| Age, min.–max. (median; years) |
53–88 (79.00) |
55–94 (82.50) |
0.21 |
| Sex, male |
24 (68.6) |
20 (52.6) |
0.16 |
| Hypertension |
20 (57.1) |
23 (60.5) |
0.77 |
| Diabetes |
10 (28.5) |
12 (31.6) |
0.78 |
| Hyperlipidemia |
11 (31.4) |
10 (26.3) |
0.63 |
| Smoking history |
18 (51.4) |
10 (26.3) |
0.02 |
| Hemodialysis |
4 (11.4) |
1 (2.6) |
0.14 |
| Coronary artery disease |
7 (20.0) |
5 (13.2) |
0.43 |
| Cerebrovascular disease |
8 (22.9) |
13 (34.2) |
0.28 |
| Atrial fibrillation |
9 (25.7) |
31 (81.6) |
<0.01 |
| Cancer |
10 (28.6) |
5 (13.2) |
0.13 |
| Antiplatelets |
22 (62.9) |
10 (26.3) |
<0.01 |
| Antithrombotic agents |
8 (22.9) |
17 (44.7) |
0.049 |
| Time from onset, median (days) |
2.0 (0–13) |
0.5 (0.5–14) |
<0.01 |
| Rutherford class 1 |
13 (37.1) |
9 (23.7) |
0.21 |
| Rutherford class 2a |
13 (37.1) |
16 (42.1) |
| Rutherford class 2b |
9 (25.7) |
13 (34.2) |
| Preoperative CK, median (U/L) |
305 (27–23,256) |
335 (17–14,883) |
0.64 |
| Max. CK, median (U/L) |
885 (31–42,645) |
1,098 (17–67,335) |
0.83 |
| Underlying lesion |
35 (100) |
14 (36.8) |
<0.01 |
| Collateral development |
32 (91.4) |
13 (34.2) |
<0.01 |
| Contralateral arterial disease |
29 (82.9) |
14 (36.8) |
<0.01 |
| Revascularization |
| Operation time, median (min) |
158 (20–530) |
122 (44–630) |
<0.01 |
| General anesthesia under intubation |
20 (57.1) |
15 (39.5) |
0.13 |
| Surgical thrombectomy |
25 (71.4) |
37 (97.4) |
<0.01 |
| Iliac artery |
6 (17.1) |
12 (31.6) |
0.153 |
| FP artery |
17 (48.6) |
31 (81.6) |
<0.01 |
| IP artery |
18 (51.4) |
16 (42.1) |
0.425 |
| Failed thrombectomy |
11 (31.4) |
4 (10.5) |
0.03 |
| Urokinase use |
15 (42.9) |
15 (39.5) |
0.769 |
| Additional revascularization |
34 (97.1) |
10 (26.3) |
<0.01 |
| Endovascular revascularization, n |
15 |
9 |
0.08 |
| Conversion to surgical treatment, n |
8 |
1 |
0.01 |
| Surgical revascularization, n |
9 |
0 |
<0.01 |
| Hybrid therapy, n |
10 |
1 |
<0.01 |
| Multi-segment treatment |
16 (45.7) |
1 (2.6) |
<0.01 |
| Failed revascularization |
3 (8.5) |
4 (10.5) |
0.55 |
| Difficulty in crossing lesions |
9 (25.7) |
1 (2.6) |
<0.01 |
| Wire use, min.–max. (median; n) |
0–4 (2.00) |
0–5 (1.00) |
0.096 |
| Sheath and catheter use, min.–max. (median; n) |
0–4 (2.00) |
0–3 (1.00) |
<0.01 |
| Device use, min.–max. (median; n) |
0–4 (2.00) |
0–4 (0.00) |
<0.01 |
| Distal emboli |
3 (8.6) |
1 (2.6) |
0.28 |
| Postoperative management |
| 30-day mortality |
3 (8.6) |
6 (15.8) |
0.28 |
| 30-day major amputation |
1 (2.9) |
2 (5.3) |
0.53 |
| Fasciotomy |
7 (20.0) |
3 (7.9) |
0.12 |
| Temporary hemodialysis use |
4 (11.4) |
6 (15.8) |
0.42 |
Unless indicated otherwise, data are presented as n (%). AoC, acute on chronic; CK, creatine kinase; FP, femoropopliteal; IP, infrapopliteal; max., maximum; min., minimum.
The rate of general anesthesia was similar between the 2 groups. However, the AoC group had longer operative times, higher rates of surgical thrombectomy, failed thrombectomy, additional revascularization, and multi-segment treatment (P<0.05 for each). Surgical and hybrid revascularization were more common in the AoC group (P<0.01), while EVT was more frequent in the embolic group (44% vs. 90%; P=0.08). Difficulty in crossing lesions was more common in the AoC group (P<0.01). Distal embolization rates were similar but higher in the AoC group (8.6% vs. 2.6%). These results suggest that the AoC group had more complex arterial lesions requiring more challenging revascularization procedures (Table 1).
In the AoCLI cases, iliac lesions were primarily treated with EVT, except for 1 femorofemoral bypass. Common femoral lesions were treated with endarterectomy. Of the 21 FP lesions, 10 were treated endovascularly, 5 with FP bypasses due to failed thrombectomy, and 3 with distal bypasses due to device crossing difficulties. Two IP diseases were also treated endovascularly.
The 30-day mortality rate was 8.6% in the AoC group and 15.8% in the embolic group (P=0.28). The 30-day major amputation rate was 2.9% in the AoC group and 5.3% in the embolic group (P=0.53). Rates of fasciotomy for compartment syndrome (P=0.12) and temporary hemodialysis for MNMS (P=0.42) were also similar between the groups (Table 1).
Impact of Underlying Arterial Lesions on Endovascular-Based Treatment
To evaluate the impact of underlying lesions, subjects were divided into 2 groups: with (n=49) and without (n=24) underlying arterial lesions. Significant clinical differences were noted (Table 2). ALI cases with underlying lesions had a longer time from onset. Underlying lesions were treated in 42 (85.7%) cases. Of 22 endovascular revascularizations, 9 (40.9%) cases failed and required surgical conversion; there was higher usage of sheaths, catheters, and treatment devices. Greater anatomical complexity in ALI cases with underlying lesions led to higher failed thrombectomy rates and increased difficulty in endovascular therapy.
Table 2.
Clinical Features of and Treatment for ALI Affected by Underlying Lesions
| |
With underlying lesions
(n=49) |
Without underlying lesions
(n=24) |
P value |
| Time from onset, min.–max. (median; days) |
0–14.00 (1.50) |
0–4.00 (0.50) |
<0.01 |
| Preoperative CK, min.–max. (median; U/L) |
27–23,256 (397.00) |
17–9,029 (209.50) |
0.097 |
| Max. CK, min.–max. (median; U/L) |
31–67,335 (912.00) |
17–16,575 (719.00) |
0.19 |
| Contralateral disease |
38 (77.6) |
5 (20.8) |
<0.01 |
| Operation time, min.–max. (median; min) |
20–630 (158.00) |
44–230 (101.50) |
<0.01 |
| General anesthesia |
28 (57.1) |
7 (29.2) |
0.02 |
| Thrombectomy |
38 (77.6) |
24 (100) |
<0.01 |
| Failed thrombectomy |
15 (30.6) |
0 (0) |
<0.01 |
| Difficulty in crossing lesions |
10 (20.4) |
0 (0) |
0.01 |
| Additional revascularization |
42 (85.7) |
2 (8.3) |
<0.01 |
| Endovascular revascularization |
22 (52.3) |
2 (8.3) |
0.003 |
| Surgical conversion |
9 (40.9) |
0 |
<0.01 |
| Surgical revascularization |
9 (26.2) |
0 |
0.02 |
| Hybrid therapy |
11 (22.4) |
0 |
<0.01 |
| Multi-segment treatment |
17 (34.7) |
0 |
<0.001 |
| Failed revascularization |
5 (10.2) |
2 (8.3) |
0.58 |
| Distal embolization |
3 (6.1) |
1 (4.2) |
0.601 |
| Wires, min.–max. (median; n) |
0–5 (2.00) |
0–2 (1.00) |
<0.01 |
| Sheaths and catheters, min.–max. (median; n) |
0–4 (1.00) |
0–2 (0.00) |
<0.01 |
| Devices, min.–max. (median; n) |
0–4 (1.00) |
0–3 (0.00) |
<0.01 |
Unless indicated otherwise, data are presented as n (%). ALI, acute lower extremity limb ischemia. Other abbreviations as in Table 1.
The treatment favorability for 62 cases of FP and IP segment occlusions was assessed by dividing them into 2 groups: Bypass Favor (21 cases), and EVT Favor (42 cases). Rutherford grade 1 was similar between the groups, but the Bypass Favor group had a significantly longer time from ALI onset. The optimal cut-off value for time from ALI onset was 2.5 days, with an AUC of 0.76 (Figure 3). Patient demographics and comorbidities were similar, except for atrial fibrillation, which was more common in the Bypass Favor group. Underlying lesions and collateral development were more common in the Bypass Favor group (P<0.01 for each; Table 3). FP and IP occlusions in preoperative CT were similar between the groups. In multivariate analysis, factors unfavorable for EVT included time from ALI onset (OR 1.4; 95% CI 1.0–2.0), non-atrial fibrillation case (OR 4.2; 95% CI 1.0–16.7), and collateral development (OR 9.0; 95% CI 1.0–81.5; Table 4). Based on these results, the failure rate of EVT increased as the number of unfavorable factors increased (Figure 4).
Table 3.
Difference in Clinical Features and Anatomical Findings Between the Bypass Favor and EVT Favor Groups
| |
Bypass favor
(n=21) |
EVT favor
(n=41) |
P value |
| Time from onset, min.–max. (median; days) |
0–14.00 (3.00) |
0–5.00 (0.50) |
<0.01 |
| Rutherford class 1 |
7 (33.3) |
12 (29.3) |
0.74 |
| Rutherford class 2a |
7 (33.3) |
18 (43.9) |
| Rutherford class 2b |
7 (33.3) |
11 (26.8) |
| Hypertension |
12 (57.1) |
24 (58.5) |
0.92 |
| Diabetes |
6 (28.6) |
14 (34.1) |
0.66 |
| Hyperlipidemia |
7 (33.3) |
12 (29.3) |
0.74 |
| Smoking history |
10 (47.6) |
15 (36.6) |
0.4 |
| Hemodialysis |
1 (4.8) |
3 (7.3) |
0.58 |
| Coronary artery disease |
3 (14.3) |
7 (17.1) |
0.54 |
| Cerebrovascular disease |
6 (28.6) |
12 (29.3) |
0.95 |
| Atrial fibrillation |
5 (23.8) |
27 (65.9) |
<0.01 |
| Cancer |
4 (19.0) |
8 (19.5) |
0.62 |
| Antiplatelets |
13 (61.9) |
15 (36.6) |
0.058 |
| Antithrombotic agents |
5 (23.8) |
15 (36.6) |
0.31 |
| Preoperative CK, min.–max. (median; U/L) |
27–23,256
(345.00) |
17–9,029
(154.00) |
0.41 |
| Preoperative WBC, min.–max. (median; /μL) |
3,500–24,190
(8,710.00) |
3,060–103,100
(8,260.00) |
0.73 |
| Underlying lesion |
21 (100) |
21 (51.2) |
<0.01 |
| Collateral development |
20 (95.2) |
20 (48.8) |
<0.01 |
| FP and IP occlusion |
7 (33.3) |
20 (48.8) |
0.25 |
| IP occlusion |
11 (52.4) |
23 (50.6) |
0.78 |
| Contralateral arterial disease |
15 (71.4) |
20 (48.8) |
0.089 |
| Urokinase use |
9 (42.9) |
19 (46.3) |
0.79 |
| Ipsilateral revascularization history |
4 (19.0) |
4 (9.8) |
0.26 |
| Intermitted claudication history |
5 (23.8) |
4 (9.8) |
0.14 |
Unless indicated otherwise, data are presented as n (%). EVT, endovascular therapy; WBC, white blood cells. Other abbreviations as in Table 1.
Table 4.
Multivariate Analysis Identified Unfavorable Factors for Endovascular Therapy
| Factor |
Univariate analysis |
Multivariate analysis |
| OR (95% CI) |
P value |
OR (95% CI) |
P value |
| Time from onset |
1.6 (1.2–2.1) |
<0.01 |
1.4 (1.0–2.0) |
0.03 |
| Intermittent claudication before onset |
2.9 (0.7–12.2) |
0.15 |
|
|
| Non-atrial fibrillation |
5.0 (2.0–10.0) |
<0.01 |
4.2 (1.0–16.7) |
0.04 |
| Antiplatelet use |
2.8 (0.9–8.3) |
0.06 |
|
|
| Collateral artery development |
21.0 (2.7–171.4) |
<0.01 |
9.0 (1.0–81.5) |
0.05 |
| Contralateral arterial lesions |
2.6 (0.9–8.1) |
0.09 |
|
|
CI, confidence interval; OR, odds ratio.
Discussion
Our results corroborated that a more gradual aggravation of symptoms in AoCLI due to arterial thrombosis on the underlying lesion is based on the longer time from onset to treatment and increased collateral circulation. Therefore, thrombectomy, as well as additional revascularization for the responsible arterial lesion, was necessary for inflow or outflow vessel perfusion. This often results in multi-segment treatment being required in AoCLI. Procedures should be performed in a hybrid room or operating room with radiation fluoroscopy equipment by a clinical team capable of offering a full range of open or endovascular interventions.
Published data that have analyzed ALI report rates of limb loss ranging from 12% to 30% in the first month after presentation, with a mortality rate of 9–15% during this period.7–10 In both the AoC group and the embolic group, our study confirmed the high 30-day mortality (8.6%, and 15.8%, respectively), and the relatively low 30-day major amputation rates (2.9%, and 5.3%, respectively). MNMS and compartment syndrome are serious complications following ALI.5 These complications are more common after revascularization of prolonged and severe ischemia.2 However, the rates of temporary hemodialysis use and fasciotomy, as well as preoperative and maximum levels of creatine kinase, were similar between the AoC group and the embolic group. Although AoCLI is known to be less severe at onset,6 a previous report showed inferior long-term limb preservation due to the progression of peripheral arterial disease compared with embolic ALI.1
In emergency settings, it was difficult to predict pre-existing underlying arterial disease with preoperative CTA due to arterial occlusion. Our study demonstrated increased operative duration, a high rate of failed thrombectomy, difficulty in crossing lesions and performing additional revascularization, and more multi-segment treatment in AoCLI. This indicates that achieving sufficient distal perfusion is more challenging in AoCLI compared with embolic ALI. Specifically, in 21 cases of FP underlying arterial lesions in AoCLI, 10 cases were treated with EVT, while 11 cases required surgical procedures due to failed thrombectomy or difficulty in crossing lesions. The underlying lesions made it more difficult for devices or Fogarty catheters to track through the diseased vessels, necessitating more wires, sheaths, and catheters, as our study demonstrated. Additionally, IP occlusion was involved in half of our patients who required surgical thrombectomy. Urokinase was previously available for thrombolysis in ALI treatment, and 40% of our cases were treated with it; however, its use has been discontinued. ALI affecting the IP segment exhibited the correlation with reduced 90-day amputation-free survival, and moreover residual clots in the IP segment after thrombectomy and underlying arterial lesions in the IP segments were associated with clinical outcomes.11,12 Mechanical thrombectomy can help treat complex arterial lesions. The Indigo system, which was launched in Japan in 2023, can perform thrombectomy and additional EVT in 1 procedure, with proven safety and efficacy, as demonstrated in the INDIAN trial.13,14 In ALI with underlying arterial disease, especially AoCLI cases, mechanical thrombectomy can improve wire and catheter trackability, facilitate angioplasty in diseased FP and IP arteries, and increase technical success rates while reducing surgical conversions.
Study Limitations
There are several limitations. First, this study is a single-center, retrospective study with a small sample size. Second, the retrospective data did not examine whether EVT was truly infeasible at the time of the initial bypass surgery. Third, all procedures were performed by vascular surgeons, and vascular surgeons have a big advantage for rapid conversion to bypass surgery, but it sometimes leads to surgical conversion too quickly; therefore, as a result, the technical success rate of endovascular therapy became lower than that of cardiologists and radiologists.
Conclusions
AoCLI had more complex and multi-segment arterial lesions, making limb perfusion restoration difficult. The unfavorable factors for EVT could help stratify the optimal treatment of ALI by EVT or surgical revascularization in emergency settings.
Acknowledgments
During the preparation of this manuscript, the authors were supported with research funds from Asahikawa Medical University Surgical Educational Support (AMUSE) Organization.
Disclosures
All authors have no conflicts of interests to declare.
IRB Information
The present study was approved by the regional ethics committee of Asahikawa Medical University (Reference no. 24097).
Data Availability
The data are available from the corresponding author on reasonable request immediately following publication and before review is completed. The data can be applied to any kind of analyses, and will be shared in an Excel file.
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