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264
Fig. 16.5 Carotid artery
stenting
C. Setacci et al.
Embolization protection strategies include distal lter protection and ow reversal
(a proximal protection device in which a triple-lumen catheter with a double balloon
was utilized to occlude the CCA and ECA; the reversed ow was then directed
through the catheter to a ltered external femoral venous system). Though ow
reversal was initially met with some scepticism, it has gained wider acceptance and
may provide the advantage of not crossing the carotid lesion before protection is
established. Carotid stenting is a new and exciting eld with rapidly advancing technologies. Embolization protection, low-risk deployment and lesion assessment and
stratication are active areas of research [4].
Although CAS has emerged as an attractive alternative to CEA in patients who
are at high risk for surgical complications, conicting data exist about the risks
associated with carotid stenting in the very elderly (≥80 years old) population.
Octogenarian patients are more likely to have baseline characteristics that
16 Cerebrovascular Disease andCritical Limb Ischaemia
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265
predispose the patient to adverse outcome including: Type III aortic arch, decreased
cerebral reserve, aortic arch calcication, excessive vessel tortuosity and severe
lesion calcication. While these characteristics represent a challenge to operators
performing CAS on octogenarian patients, they do not constitute absolute contraindications to the procedure. It is noteworthy that the outcomes in this patient population seem to correlate with operator experience [5].
16.2 Critical Limb Ischaemia (Figs.16.6, 16.7, 16.8, and16.9)
Critical limb ischaemia (CLI) is a manifestation of peripheral arterial disease (PAD)
that describes patients with typical chronic ischaemic rest pain (Tables 16.1 and
16.2) or patients with ischaemic skin lesions, either ulcers or gangrene. The term
CLI should only be used in relation to patients with chronic ischaemic disease,
dened as the presence of symptoms for more than 2weeks. The diagnosis of CLI
should be conrmed by the ankle-brachial index (ABI), toe systolic pressure or
transcutaneous oxygen tension. Ischaemic rest pain most commonly occurs below
an ankle pressure of 50mmHg or a toe pressure<30mmHg. Other causes of pain,
a rest should, therefore, be considered in patients with an ankle pressure>50mmHg,
although CLI could be the cause. Some ulcers are entirely ischaemic in aetiology;
others initially have other causes (e.g. traumatic, venous or neuropathic) but will not
heal because of the severity of the underlying PAD.Healing requires an inammatory response and additional perfusion above that required for supporting intact skin
and underlying tissues. The ankle and toe pressure levels needed for healing are,
therefore, higher than the pressures found in ischaemic rest pain. For patients with
Fig. 16.6 and 7 Ulcers with tendon exposition
266
Fig. 16.8 and 9 Hybrid approach: F-P bypass + angiograc control and PTA tibial vessels
C. Setacci et al.
Table 16.1 Fontaine classication of peripheral
arterial disease
Table 16.2 Rutherford classication of peripheral
arterial disease
Stage Clinical
I Asymptomatic
IIa Mild claudication
IIb Moderate to severe claudication
III Ischaemic rest pain
IV Ulceration or gangrene
Stage
Grade
0 0 Asymptomatic
I 1 Mild claudication
I 2 Moderate claudication
I 3 Severe claudication
II 4 Ischaemic rest pain
III 5 Minor tissue loss
III 6 Major tissue loss
Clinical
ulcers or gangrene, the presence of CLI is suggested by an ankle pressure<70mmHg
or a toe systolic pressure>50mmHg. CLI population are difcult to study, with
large numbers of patients lost to follow-up or dying in longitudinal studies, leading
to incomplete data sets. The incidence of CLI, based on large prospective population studies, is of 220 new cases every year per million population [6]. Although the
diagnosis of arterial occlusive disease of the lower limb could be made on the basis
of history and physical examination, imaging is mandatory for localization and
quantication of the arterial lesions. Traditionally intraarterial digital subtraction
arteriography (DSA) is considered the diagnostic standard to evaluate the lower
extremity arterial tree. However, DSA is invasive and may be associated with welldocumented limitations that make this method unsuitable for screening or follow-up
examinations. Other limitations for the use of DSA as routine diagnostic technique
include the need of catheterization, contrast allergic reactions, arterial injury, haemorrhage, atheroembolism, potential pseudoaneurysm formation at the puncture site
and most importantly contrast-induced nephropathy despite the use of non-ionic
16 Cerebrovascular Disease andCritical Limb Ischaemia
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267
contrast media. Furthermore, even with bi-planar views, arteriography can underestimate the severity of eccentric arterial stenosis. For these reasons, many forms of
less invasive modalities include multidetector tomography angiography, magnetic
resonance angiography (MRA) and duplex ultrasonography (DU) that have been
devised for grading lower extremity arterial disease. In the last few years, several
studies have raised the possibility of using DU arterial mapping as the sole investigation method to assess the most suitable treatment plan for CLI.In fact, this noninvasive method, with colour Doppler technology, if used appropriately, provides
most of the essential anatomic information plus haemodynamic data for extensive
peripheral arterial mapping and allows to distinguish between thigh stenosis and
occlusion, to determine the grade of stenosis severity into multiple levels during
pre-operatory study. Moreover, it can be used as a follow-up exam [7].
As regards the treatment, CLI has always been considered a primary indication
for bypass surgery. Nevertheless, not all patients with CLI can undergo surgical
revascularization because of prohibitive surgical risk or anatomical unfavourable
conditions. The ideal treatment for CLI lesions has raised great amount of discussion and controversy among specialists. Aside from differing opinions regarding the
preferred method of treatment, specialists suggest that many additional variables
must be considered: lesion location, severity, degree of calcication and the patient’s
associated symptoms. Limb salvage rates >90% at 1year are reported in recent
series using bypass surgery. Unfortunately, an adequate vein is often unavailable,
and long-term results of bypasses constructed with prosthetic materials are much
less satisfactory. Nowadays the use of endovascular procedures as primary treatment for CLI has increased due to the continuous advances in imaging techniques,
angioplasty equipment (i.e. low-prole balloons and new guidewires) and endovascular expertise. The clinical advantages of the endovascular approach in CLI are
well established, especially for high-risk, elderly and vascular compromised
patients: there is no need for general or spinal anaesthesia; there are few or no surgical wounds, especially risky in diabetic patients; the hospital stay is shorter; complication and mortality rates are low; and a failed angioplasty attempt does not preclude
a subsequent bypass graft. Therefore, it’s important (1) to identify the patient
(comorbidities), (2) to identify the lesion location/extension and (3) to distinguish
between haemodynamically signicant and non-signicant lesions in order to establish the optimal revascularization treatment for CLI.Treatment strategy is strongly
determined not only by the type of lesion but also by the anatomical site, since there
are large differences in approaches and outcomes for proximal lesions on large vessels (aortoiliac) and distal lesion on small vessels (tibial arteries). In 2000 and 2007,
the TransAtlantic Inter-Society Consensus (TASC) allowed stratication by length
and morphology of lesions (iliac occlusive disease and femoropopliteal and infrapopliteal lesions) and reinforced the concept of treating short, focal stenoses (TASC
A lesions) via endovascular means and using surgical revascularization for longsegment occlusions (TASC D lesions). In cases of diffused aortoiliac occlusive disease although aortobifemoral bypass appears to have better long-term patency than
endovascular treatment, the risks of surgery are signicantly greater than the risk of
an endovascular approach, in terms not only of mortality but also of major
268
C. Setacci et al.
morbidity and delay in return to normal activities. As regards the femoropopliteal
and infrapopliteal disease, PTA is the primary option for short and focal disease
<3cm in length; for lesions that are between 3 and 5cm in length, there are too
many variables to recommend a single treatment protocol. If a patient has vessels
with a poor runoff, small vessels and calcied lesions that are 5–10cm in length, the
surgical option may be the optimal treatment. For patients with high comorbidities,
the ideal treatment seems to be endovascular (bare metal stent or stent graft).
Endovascular procedures below the popliteal artery are usually indicated for limb
salvage, and there are no data comparing endovascular procedures to bypass surgery
for intermittent claudication in this region. PTA seems to be feasible and effective
in patients with CLI and infrapopliteal artery occlusion.
The techniques used are:
– Angioplasty: PTA of a short anterior or posterior tibial artery stenosis may be
performed in conjunction with popliteal or femoral angioplasty. Treatment of
longer lesions is often more complex and has a worse prognosis than treatment
of short lesions.
– Stents: stent application in below-the-knee vessels remains highly controversial;
the high risk of early thrombosis and luminal loss due to intimal hyperplasia
formation leading to insufcient long-term patency rates can explain the reluc-
tance on implanting stents in these small diameter vessels. Infrapopliteal stent
implantation is generally reserved for cases with suboptimal outcome after PTA.
– Cutting balloon: this technique decreases vessel elastic recoil and perivascular
injury by a focal concentration of dilatation force.
– Subintimal angioplasty: this technique, by passing a wire into the subintimal
space and inating a balloon to create a channel for blood ow, is largely
employed for long-segment occlusion below the knee recanalization [8].
Several endovascular devices have been shown to be safe and feasible in the
infrapopliteal segment but have failed to show superiority when compared with
PTA.The development of self-expanding nitinol stent has improved the therapeutic
outcome of femoropopliteal lesions compared with conventional angioplasty.
However, restenosis remains a key unresolved issue. Restenosis usually occurs
6months after the implantation of bare nitinol stents, with a peak onset at 12months.
In an effort to curb restenosis, manufacturers engineered stents to elute antiproliferative agents. Drug-eluting stents (DES) signicantly reduced restenosis rates
compared with bare stents [9].
However, the employment of DES did not give good results in infrapopliteal
arteries where restenosis rates remain high. The favourable results of below-theknee (BTK) DES treatment were limited to PTA of short lesions that are not representative of the diffuse BTK vessel disease typical of diabetic patients with CLI.The
cause of these difculties with regard to peripheral angioplasty and stenting in
obtaining acceptable good long-term patency rate resides in the peculiar
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269
characteristics of the infrainguinal vessel physiology and disease: in patients with
CLI, infrainguinal vessels have a multisegmental and diffuse disease which necessitate an extensive treatment, resulting in an extraordinary mean length of the treated
PTA lesions (it is well known that restenosis is proportional to the length of the
treated vessel); inferior limb arteries undergo intense mechanical stress due to hip,
knee and ankle movements, muscle contraction and to the interaction of the limb
with external bodies during daily activities (standing up, sitting, walking, lying,
etc.); stents interfere with the original physical behaviour of the arteries, leading to
chronic mechanical stress, fractures, inammation and subsequent restenosis [10].
With this in mind, faced with the limits of peripheral angioplasty and stenting in
infrainguinal vessels, the drug-eluting balloon (DEB) presents some advantages
with respect to DES and seems able to prevent restenosis and to avoid, when possible, the metallic burden of stenting [11].
Given the evolving demographics and the increasing prevalence of CLI with age
in Western countries, there has been an enhanced focus on developing safe and
effective treatment. Related to endovascular and surgical options, in recent years the
hybrid approach (the combination of the two techniques) is considered an interesting alternative approach to improve life expectancy of patients with CLI.This treatment is reserved for patients with a multilevel disease (involvement of more than
two districts among the iliac, the femoral, the popliteal and the tibial areas) or a
previous surgical intervention or an adequate length of the greater saphenous vein
or leg ulcer prohibiting distal graft implantation. In the CA, the union of the endovascular and surgical techniques was used to complete the revascularization in different anatomical districts or to correct inadequate results of the rst procedure
(inadequate inow or outow) or to correct inadequate results due to iatrogenic
complications of the rst technique (arterial rupture or residual dissection) [12].
The treatment of CLI in the United States has been characterized as a pathway to amputation, as 67% of Medicare patients who underwent a major amputation did not have any other exploratory or therapeutic procedures prior to
losing their limb. This nding was conrmed in a recent study of 20,464
Medicare patients with CLI who underwent amputations, which revealed that
71% had no revascularization and 54% did not even undergo angiography,
underscoring the fact that revascularization procedures (endovascular and surgical) have largely been underutilized. This could be ascribed, at least in part, to
the paucity of randomized control trials (RCTs) comparing both strategies,
which have been difcult to implement. This represents an example of the existing gap between “real-world CLI practices” and the availability of evidencebased therapies [
13].
In conclusion CLI continues to be a signicant challenge to the vascular surgeon.
Despite great advances in the treatment of CLI, a signicant number of amputations
are still performed. Limb salvage may represent the goal even if, unfortunately,
some patients still require primary amputation due to many variables which are
impossible to resolve.
270
C. Setacci et al.
References
1. Michalinos A, Chatzimarkos M, Arkadopoulos N, etal. Anatomical consideration on surgical
anatomy of the carotid bifurcation. Anat Res Int. 2016;2016:1–8.
2. ACST-2 Collaborative Group. Status update and interim results from the Asymptomatic
Carotid Surgery Trial-2 (ACST 2). Eur J Vasc Endovasc Surg. 2013;46(5):511–8.
3. O’Brien M, Chandra A.Carotid revascularization: risk and benets. Vasc Health Risk Manag.
2014;10:103.
4. Morr S, Lin N, Siddqui AH.Carotid artery stenting: current and emerging options. Med
Devices Evid Res. 2014;7:343.
5. Grant A, White C, Ansel G.Safety and efcacy of carotid stenting in the very elderly. Catheter
Cardiovasc Interv. 2009;75(5):651–5.
6. De Donato G, Chisci E, Setacci F, etal. Critical limb ischemia: denition, epidemiology and
economic impact. Chapter I. Critical limb ischemia. New developments and perspectives.
2010.
7. Benedetti-Valentini F, etal. Arterial mapping by duplex scanning in patients with CLI: Chapter
IV.New developments and perspectives. 2010.
8. Brambilla D, Casalino A, Barbante M, etal. Decision chart for optimal endovascular treat-
ment. Chapter 6. New developments and perspectives. 2010.
9. Soga Y. Can new drug-eluting stents put an end to the debate? J Endovasc Ther.
2016;23(5):708–9.
10. Schlager O, Dick P, Sabeti S, etal. Long-segment SFA stenting- the dark sides: in-stent reste-
nosis, clinical deterioration and stent fractures. J Endovasc Ther. 2005;12:676–84.
11. Ferrares R, Aprigliano A, Palloshi A, etal. Drug-eluting balloon technologies and results. How
drug eluting balloon going to chance our practice? Chapter XVI.Critical limb ischemia. New
developments and perspectives. 2010.
12. Setacci C, Galzerano G, Sirignano P, etal. The role of hybrid procedures in the treatment of
critical limb ischemia. J Cardiovasc Surg. 2013;54:729–36.
13. Diaz-Sandoval LJ, Mustapha JA, Saab F. Evidence-based CLI therapies in 2016. Endovasc
Today Eur. 2016;4(4).
Acute Peripheral Arterial Disease
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17
FrancescoSpeziale, PasqualinoSirignano, SimoneCuozzo,
WassimMansour, ChiaraPranteda, MartinaFormiconi,
Alessandrod’Adamo, andLauraCapoccia
17.1 Introduction
Acute limb ischemia (ALI) is a pathological condition resulting from a sudden
blood interruption (or, at least, from an important reduction in ow) limiting tissues’ survival [1]. ALI is always a serious event requiring immediate diagnosis and
treatment, also considering the high associated amputation risk (from 10% to 25%).
Unfortunately, ALI is not a rare occurrence, with an estimated incidence of about
1.5 new cases per 10,000 person/year [2].
The most frequent causes of acute limb ischemia are embolism, thrombosis, and
trauma [3]. Symptoms include intermittent claudication, rest pain, paresthesia, muscle weakness, anesthesia, and paralysis. Physical examination could be characterized by the absence of pulses distally to the occlusion site, hypothermia, and pale or
mottled skin.
Those clinical ndings are grouped together in a series mnemonic note as “6P of
Pratt”: pain, pallor, pulselessness, poikilothermia, paresthesia, and paralysis.
All those data—in association with a duplex ultrasound scan (DUS)—allow classication of the syndrome into different classes of severity as reported by Rutherford
in 1997 (Table17.1) [4].
Considering the peculiarity of the symptoms and their frequent (if not constant)
association, the diagnosis of ALI is mainly based on clinical features. The instrumental investigations, however, are indispensable to obtain a diagnosis of certainty,
to recognize the causes, and to have correct treatment planning (open surgery, endovascular surgery, hybrid procedures, or brinolytic treatment) [
5].
F. Speziale • P. Sirignano (*) • S. Cuozzo • W. Mansour • C. Pranteda • M. Formiconi •
A. d’Adamo • L. Capoccia
Vascular and Endovascular Surgery, Department of Surgery “Paride Stefanini”, “Policlinico
Umberto I”, “Sapienza” Università di Roma, Viale del Policlinico, 155, 00161 Rome, Italy
e-mail: Francesco.speziale@uniroma1.it; pasqualino.sirignano@uniroma1.it;
laura.capoccia@uniroma1.it
© Springer International Publishing AG, part of Springer Nature 2018
A. Crucitti (ed.), Surgical Management of Elderly Patients,
https://doi.org/10.1007/978-3-319-60861-7_17
271
272
Table 17.1 Clinical stages of acute limb ischemic syndrome (edited by the Society for Vascular
Surgery standards [4])
Description and
Stage
prognosis
I Limb vital, not
immediately
threatened
II Limb threatened
IIa Limb marginally
threatened that can
be saved if treated
promptly
IIb Limb immediately
threatened,
recoverable with
immediate
revascularization
III Limb irreversibly
damaged, major
tissue loss, or
permanent damage
to the inevitable
nerves
Objectivity Doppler signal
Sensory damage Muscle weakness Arterial Venous
Absent Absent Present Present
Minimum (limited to
the ngers) or absent
Extended beyond the
ngers, associated
with pain
Spread/anesthesia Severe/paralysis Absent Absent
Absent Often
Medium or
moderate
F. Speziale et al.
absent
Often
absent
Present
Present
17.2 Physiopathology andDiagnostic Evaluation
DUS in concert with the clinical features assumes a primary and crucial role in
diagnostic and preoperative evaluation of ALI patients. The bidimensional (B-Mode)
ultrasound provides the typical image of endoluminal material, presenting variable
echogenicity. In cases of embolic occlusions, generally, it is not possible to observe
atherosclerotic lesions, while typical atherosclerotic lesions will be more frequently
found in cases of thrombotic genesis of the syndrome. Moreover, DUS allows evaluation of the pathognomonic sign of meniscus and the absence of color signal
downstream. DUS also evaluates the complete absence of ow signal at the level of
the occlusion.
Upstream and downstream of the stretch of the acutely occluded vessel, it may be
possible to highlight characteristic indirect signs of ALI: increased resistance and pulsatility of the blood ow (increases modulation of the curve with the amplitude reduction). In cases, with the absence of collateral circulation, there will not be any
detectable DUS signal in downstream vessels; instead, in cases with a preexisting
collateral circulation, DUS signal will be present with a curve characterized by a clear
reduction in resistance indices and secondary pulsatility at the reduction of systolicdiastolic modulation. In most severe cases, the curve assumes a continuous form.
Accuracy, sensitivity, and specicity of DUS are 86, 84, and 89%, respectively [6].
A fundamental aspect (unfortunately, not always easy to interpret) is the differential diagnosis between embolism and thrombosis, a crucial aspect in choosing
different treatment options [7].
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Indeed, in consideration of the difculty in distinguishing embolic and thrombotic arterial occlusion, in recent years the vascular surgery team of Cairo published
two articles with the aim of helping the vascular surgeon in this difcult differential
diagnosis.
In 2010 Elmahdy etal. performed a study of 107 surgically treated ALI.To be
able to make an accurate diagnosis of the etiology of ALI (embolic versus thrombotic) without the use of angiography (gold standard for this condition but not free
of risk, with an overall complication rate of about 2%), they have examined several
parameters such as risk factors, systemic vascular atherosclerosis, time of symptom
onset, and clinical presentation. The presence of atherosclerotic vascular disease
was dened based on the presence of one myointimal thickness>0.1mm. They also
rated the arterial diameter (intima-intima) at the level of the occlusion (d
pared to the diameter at the same artery level in the contralateral limb (d
difference between these two diameters (Δ=d
occl−dcontrol
) was calculated. Patients
occl
control
), com-
). The
were consequently divided into two groups: embolic ALI (Group E) and thrombotic
ALI (Group T). No statistically signicant differences were found between the two
groups for any examined features (calcications, collateral circulation, atrial brillation), except for Δ diameter. In Group E, the Δ diameter results were
0.95±0.92mm, while in Group T, results were −0.13±1.02mm (p:<0.001). Their
results show an increase in the diameter of vessels in embolic etiology of ALI and,
even though minimal, an average reduction of the diameter of vessels in thrombotic
etiology of this syndrome. Analyzing ROC curves, the authors stated that a change
in diameter of ±0.5mm between the occluded vessel and the contralateral one could
be considered as a valid DUS cutoff to differentiate embolic from thrombotic ALI,
with a sensitivity of 85% and a specicity of 76% (CI 0.72–0.90, p<0.007) [8–10].
Otherwise, when emboli origin is macroscopically evident, such as in case of a
popliteal aneurysm, it should be easier to recognize the embolic etiology of the
syndrome. Up to 60% of popliteal aneurysm is presenting with ALI due to distal
mobilization of aneurysmal intraluminal thrombus [11, 12]. DUS is considered the
technique of choice in those situations, allowing evaluation of the localization and
size of the aneurysm, amount and characteristics of the intraluminal thrombus, and
patency of the aneurysms and the outow vessels.
From a diagnostic point of view, another important problem to solve is represented
by ALI resulting from a failure of previous recanalization surgery. Those failures usually present with acute symptom onset, with an incidence ranging between 10%
(within 14days after surgery, early thrombosis) and 30% (within 2years of follow-up,
late thrombosis) [
13, 14]. DUS, the method of choice in lower limb revascularizations
follow-up, showed a sensitivity of 95% and a specicity of 100% in diagnosis and
localization of occlusion and stenosis >50% after bypass (either prosthetic or vein)
and after endovascular revascularization (angioplasty, stenting, and endo-bypass).
Occluded vessels may be characterized by complete absence of DUS signal, variously
associated with intraluminal material [15] (Fig.17.1).
Another important and relatively new cause of ALI is represented by thrombosis
of the percutaneous access site after endovascular treatment. The underlying causes
can be divided into distal embolization of atheromatous material, intimal ap, and
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