The prevalence of peripheral arterial disease (PAD) in patients with end-stage renal disease (ESRD) is high, with an annual risk of amputation estimated at 13%, and indications for limb revascularization in patients combining ESRD with stage IV PAD (foot gangrene) are still controversial. This case-controlled study compared survival, limb salvage, and quality of life in a group of patients hospitalized for foot gangrene according to their renal status (ESRD versus no renal insufficiency). All patients with ESRD hospitalized for foot gangrene (n=16) from 1996 to 2002 were compared with a control group with normal creatininemia (n=24) hospitalized for foot gangrene due to peripheral atherosclerotic arterial disease. The 2 groups were matched for age, sex ratio, and number with diabetes mellitus. After a mean follow-up of 467 ±410 days, patients with ESRD had a more severe prognosis as regards mortality (68.7% vs 12.5%, p=0.0005) and major amputation (31% versus 8%, p=0.09). The ESRD group was characterized by more frequent extensive arterial calcifications (16/16 vs 13/24, p=0.002), owing to a higher level of the calcium phosphorus product (3.54 ±1.2 vs 2.4 ±0.6, p=0.0023), and by impaired microcirculatory perfusion, as indicated by a lower oxygen pressure (TcPO 2 ) (15.6 ±12 mm Hg vs 26 ±16, p=0.07). ESRD implies a poor prognosis in patients with stage IV peripheral arterial disease.
Introduction - Venous stenting is nowadays recognized as the first line treatment of chronic iliac vein obstructive disease.1 The goal of this study is to review our experience of patients having a complete occlusion of at least one venous segment of the iliac veins or the inferior vena cava (IVC). Methods - From November 1995 to February 2017, 403 patients were admitted for the treatment of chronic iliac vein obstructive disease and prospectively included in a database. Of these, 162 (103 women, median age 45 years (range 16-86)) had a complete total occlusion of at least one venous segment on the iliac veins or on the IVC while excluding 7 patients involved in the Virtus study. CEAP class was C2 in 4 cases, C3 in 121, C4 in 13, C5 in 2 and C6 in 22 and 148 patients suffered from venous claudication. Median preoperative Villalta scores, VCSS and VDS were 9, 10 and 3. The Etiology was postDVT in 148 cases, retroperitoneal fibrosis in 9, May-Thurner syndrome in 2 and cancer in 3. Twenty three had previous procedures on deep veins including 11 IVC clip or filter, 10 surgical venous thrombectomy and 3 bypass. A thrombophilia was found in 45 cases. The median number of diseased and of occluded venous segments were respectively 3 (1-8) and 2 (1-7). The CFV was involved in 119 cases (55 occlusions) and the IVC in 44 cases (occluded in 44). All procedures were performed in the operating room, under general anesthesia (43) or local plus sedation (120) with a percutaneous access in 154, echo-guided in 135 (since 2006). Results - Technical success rate was 85.8%. The 23 failures never cause worsening of the clinical status or of the anatomic lesions. A median 3 stents (1-8) were used per patients for a median 230 mm of stented vein (60-490). Two IVC clip and 5 filters were stented. One clip was surgically removed. An associated endophlebectomy was performed in 14 cases with an arterio-venous fistula in 9. Median length of stay was 2 days (1-23). Median follow-up was 42 months (range 1-209). Six patients died during follow-up after a median 36 months follow-up, all with a patent venous reconstruction. The primary, assisted primary and secondary patency rates were respectively 84%, 88% and 90% at one year and 63%, 82% and 87% at 10 years. While excluding endophlebectomies, these rates were respectively 88%, 92% and 92% at one year and 65%, 86% and 88% at 10 years. The median Villalta and VDS scores of recanalized patients were 3 (0-15) and 1 (0-3) at the end of the follow-up. All C6 patients who had successful recanalization healed without recurrence but one who had rethrombosis. Conclusion - Recanalization of occluded iliac veins and/or IVC is an efficient and sure treatment that provide good long-term results in terms of clinical outcome and patency rates. References1.Management of Chronic Venous Disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Wittens C et al. Eur J Vasc Endovasc Surg. 2015 Jun;49(6):678-737.
