Arterial thrombotic complications in COVID-19 patients

The coronavirus disease 2019 (COVID-19), a viral respiratory illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been described to predispose to thrombotic disease in both the venous and arterial circulations. We report four cases of an acute arterial occlusion in COVID-19 patients and literature review on the occurrence of arterial thrombosis in patients with COVID-19. Our findings demonstrate that physicians should be vigilant for signs of thrombotic complications in both hospitalized and new COVID-19 patients

Frailty and functional outcomes after open and endovascular procedures for patients with peripheral arterial disease:A systematic review

Background: Frailty has been associated with postoperative complications and mortality across surgical specialties, including vascular surgery. However, the influence of frailty on postoperative functional outcomes is unclear. We sought to determine the influence of frailty on functional outcomes after open or endovascular vascular procedures in patients with peripheral arterial disease. Methods: This systematic review was conducted according to the PRISMA guidelines. Eligible articles were identified through database searches of Pubmed and EMBASE in April 2017. Studies reporting on frailty and functional outcomes after vascular interventions for peripheral artery disease (PAD) were included. Outcomes of interest were dependency in activities of daily living (ADL), dependent mobility, discharge destination, disability-free survival, and quality of life. Individual studies were assessed for quality and risk of bias using the Quality in Prognosis Studies tool. Results: Eight studies met the eligibility criteria and were included. The risk of bias was low in two studies, intermediate in three studies, and high in three studies. Methods for frailty assessment were different for each study. Frailty was a predictor for discharge to a higher level of care, dependent mobility, and dependency in ADL after vascular procedures for PAD. Both frailty models and individual frailty characteristics seem to be associated with these adverse functional outcomes. Conclusions: Despite a limited amount of literature and an overall intermediate quality of the included studies, this systematic review shows an association between frailty and adverse functional outcomes after peripheral arterial procedures for PAD, including discharge to a care facility, dependent mobility, and a decline in ADL functioning

Comparing Venous Reconstructions and Antimicrobial Graft Reconstructions in Mycotic Abdominal Aortic Aneurysms and Aortic Graft Infections

Background: The perioperative mortality and morbidity rates of surgical repair of mycotic abdominal aortic aneurysms and aortic graft infections are high, and the appropriate treatment is debated. This retrospective study compared venous and antimicrobial prosthetic aortic graft reconstructions. Methods: All patients of the Northwest Clinics and St. Antonius Hospital who were treated for mycotic abdominal aortic aneurysms or aortic graft infections between January 1, 2008, and January 1, 2018, were analyzed. Exclusion criterion was treatment other than venous or antimicrobial reconstructions. Primary end points were 30-day complications and mortality rates and 3-year overall survival. Secondary end points were reintervention-free survival, persistent infection and reinfection rates, and hospital length of stay. Results: Fifty-one patients met the inclusion criteria, of whom 32 underwent venous reconstructions and 19 antimicrobial prosthetic aortic graft reconstructions. Baseline characteristics did not differ significantly between these groups, except for duration of surgical repair, which was longer in the venous group. The 30-day and 1-year mortality rates, reinfection rates, complication rates, and hospital length of stay did not significantly differ between the groups. The 3-year overall survival was 77% for venous reconstruction compared with 66% for antimicrobial reconstruction (P = 0.781). The 30-day reintervention rate was 19% for the venous group compared with 42% for the prosthetic group (P = 0.071). Reintervention-free survival at 3 years was 46% for the venous group compared with 52% for the prosthetic group (P = 0.615). Conclusions: Venous reconstruction tends to have better 3-year overall survival and lower 30-day reintervention rates compared with antimicrobial prosthetic graft reconstruction in patients with mycotic abdominal aortic aneurysms or abdominal aortic graft infections. In the acute setting, antimicrobial prosthetic graft reconstruction is a valuable solution due to the shorter operation time and similar 30-day mortality and complication rates

Nuclear imaging for diagnosing fracture-related infection

Purpose Fracture-related infection (FRI) is a complication of surgical fracture treatment and can be challenging to diagnose. Recent studies show promising results for the use of either FDG-PET/CT or WBC/anti-granulocyte scintigraphy. The purpose of this pictorial essay is to outline recent developments in nuclear imaging techniques to diagnose FRI. Methods The current literature on this topic is reviewed. Additionally, three examples of patients who underwent nuclear imaging as part of their clinical work-up and surgical treatment for FRI are presented. Results Based on recent retrospective studies, FDG-PET/CT (accuracy 0.83) and WBC scintigraphy with SPECT/CT (accuracy 0.92) both have a good diagnostic accuracy for diagnosing fracture-related infection. Nuclear imaging contributes to a correct diagnosis in patients with FRI. Conclusion Retrospective studies show promising results for both FDG-PET/CT and WBC scintigraphy with SPECT/CT in diagnosing FRI. A prospective, multicenter study (IFI trial), directly comparing MRI, FDG-PET/CT, and WBC scintigraphy with SPECT/CT in patients with suspected FRI, is currently in progress

Mid-term outcomes of an everolimus-eluting bioresorbable vascular scaffold in patients with below-the-knee arterial disease:A pooled analysis of individual patient data

Previous studies on everolimus-eluting bioresorbable vascular scaffolds (BVS) have shown promising 1-year primary patency rates in infrapopliteal arteries. Literature from large cohorts on long-term outcomes with the infrapopliteal Absorb BVS (Abbott Vascular) is lacking. The aim of this study is to pool published and unpublished data to provide a more precise estimate of the 24-month outcomes of Absorb BVS for the treatment of infrapopliteal disease. For the pooled analysis, updated original and newly collected data from three cohorts on treatment with the Absorb BVS for de novo infrapopliteal lesions were combined. The primary endpoint was freedom from restenosis. Secondary endpoints were freedom from clinically driven target lesion revascularization (CD-TLR), major amputation and survival. The pooled analysis included a total of 121 patients with 161 lesions, treated with 189 Absorb BVS in 126 limbs. The mean age of the patients was 73 years, 57% had diabetes mellitus, and 75% were classified as Rutherford-Becker class 5 or 6. Of the 161 lesions, 101 (63%) were calcified and 36 (22%) were occlusions. Successful deployment was achieved with all scaffolds. Freedom from restenosis was 91.7% and 86.6% at 12 and 24 months, respectively, and freedom from CD-TLR was 97.2% and 96.6%. Major amputation occurred in 1.6% of the limbs. Overall survival was 85% at 24 months. In conclusion, this pooled analysis represents the largest reported analysis of mid-term results of the Absorb BVS for the management of chronic limb-threatening ischemia. At 24 months, the Absorb BVS was safe with promising clinical outcomes for the treatment of infrapopliteal disease

White Blood Cell Scintigraphy for Fracture-Related Infection:Is Semiquantitative Analysis of Equivocal Scans Accurate?

Purpose: White blood cell (WBC) scintigraphy is considered the gold-standard nuclear imaging technique for diagnosing fracture-related infection (FRI). Correct interpretation of WBC scans in FRI is important since a false positive or false negative diagnosis has major consequences for the patient in terms of clinical decision-making. The European Association of Nuclear Medicine (EANM) guideline for correct analysis and interpretation of WBC scans recommends semiquantitative analysis of visually equivocal scans. Therefore, this study aims to assess the diagnostic accuracy of semiquantitative analysis of visually equivocal WBC scans for diagnosing FRI. Methods: A retrospective single-center study was performed in consecutive patients who received WBC scintigraphy in the diagnostic work-up for FRI between February 2012 and January 2017. All the visually equivocal scans were analysed using semiquantitative analysis by comparing leukocyte uptake in the manually selected suspected infection focus with the contralateral bone marrow (L/R ratio). Cut-off points for a ‘positive’ scan result of >0%, >10% and >20% leukocyte increase between the early and late scans were used in separate analyses. The discriminative ability was quantified by calculating the sensitivity, specificity and diagnostic accuracy. Results: In total, 153 WBC scans were eligible for inclusion. After visual assessment of all the scans, 28 visually equivocal scans were included. Dichotomization of the ratios using the cut-off of >0% resulted in a sensitivity of 30%, a specificity of 45% and a diagnostic accuracy of 40%. The >10% cut-off point resulted in a sensitivity of 18%, a specificity of 82% and a diagnostic accuracy of 66%. The >20% cut-off point resulted in a sensitivity of 0%, a specificity of 89% and a diagnostic accuracy of 67%. Conclusion: Semiquantitative analysis of visually equivocal WBC scans is insufficient for correctly diagnosing FRI

Development of a Prediction Model for the Occurrence of Stenosis or Occlusion after Percutaneous Deep Venous Arterialization

Percutaneous deep venous arterialization (pDVA) is a promising treatment option in patients with chronic limb-threatening ischemia. Stenosis and occlusions, which are the Achilles' heel of every revascularization procedure, can be treated when detected early. However, frequent monitoring after pDVA is required because when stenosis or occlusions develop is unknown. Therefore, patients currently need to visit the hospital every 2 weeks for surveillance, which can be burdensome. Accordingly, we aimed to develop a model that can predict future stenosis or occlusions in patients after pDVA to be able to create tailor-made follow-up protocols. The data set included 343 peak systolic velocity and 335 volume flow measurements of 23 patients. A stenosis or occlusion developed in 17 patients, and 6 patients remained lesion-free. A statistically significant increase in the risk of stenosis or occlusion was found when duplex ultrasound values decreased 20% within 1 month. The prediction model was also able to estimate a patient-specific risk of future stenosis or occlusions. This is promising for the possibility of reducing the frequency of follow-up visits for low-risk patients and increasing the frequency for high-risk patients. These observations are the starting point for individual surveillance programs in post-pDVA patients. Future studies with a larger cohort are necessary for validation of this model

Short-Term Clinical Outcomes of Single Versus Dual Antiplatelet Therapy after Infrainguinal Endovascular Treatment for Peripheral Arterial Disease

After infrainguinal endovascular treatment for peripheral arterial disease (PAD), it is uncertain whether single antiplatelet therapy (SAPT) or dual antiplatelet therapy (DAPT) should be preferred. This study investigated major adverse limb events (MALE) and major adverse cardiovascular events (MACE) between patients receiving SAPT and DAPT. Patient data from three centers in the Netherlands were retrospectively collected and analyzed. All patients treated for PAD by endovascular revascularization of the superficial femoral, popliteal, or below-the-knee (BTK) arteries and who were prescribed acetylsalicylic acid or clopidogrel, were included. End points were 1-, 3-, and 12-month MALE and MACE, and bleeding complications. In total, 237 patients (258 limbs treated) were included, with 149 patients receiving SAPT (63%) and 88 DAPT (37%). No significant differences were found after univariate and multivariate analyses between SAPT and DAPT on 1-, 3-, and 12-month MALE and MACE, or bleeding outcomes. Subgroup analyses of patients with BTK treatment showed a significantly lower 12-month MALE rate when treated with DAPT (hazard ratio 0.33; 95% confidence interval 0.12-0.95; p = 0.04). In conclusion, although patient numbers were small, no differences were found between SAPT and DAPT regarding MALE, MACE, or bleeding complications. DAPT should, however, be considered over SAPT for the subgroup of patients with below-the-knee endovascular treatment