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Angiessccy: Open AogolAngiology: Open AccessISSN: 2329-9495Elshafei et al., Angiol 2018, 6:4DOI: 10.4172/2329-9495.1000219Research ArticleOpen AccessRoutine versus Selective Angiography after Embolectomy in Acute LowerLimb Ischemia: A Prospective Randomized Clinical TrialAmr Elshafei, Khalid Mowafy*, Mosaad Soliman and Abdelsalam MegahedDepartment of Vascular and Endovascular Surgery, Mansoura College of Medicine, Mansoura University, Egypt*Corresponding author: Khalid Mowafy, Department of Vascular and Endovascular Surgery, Mansoura College of Medicine, Mansoura University, Egypt, Tel: 201021205834; E-mail: Khalid mowaphy@mans.edu.egReceived date: October 03, 2018; Accepted date: October 23, 2018; Published date: October 31, 2018Copyright: 2018 Elshafei A, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricteduse, distribution, and reproduction in any medium, provided the original author and source are credited.AbstractBackground: Introduction of endovascular tools in the treatment of acute limb ischemia gave us a lot ofpromising outcomes, and many authors recommended the completion angiogram as a routine procedure after eachopen embolectomy, this recommendation was based upon some retrospective cohort studies.Objectives: The effectiveness of routine completion angiogram after embolectomy compared to selective use ofcompletion angiogram.Participants: 126 patients with 134 limbs diagnosed with acute ischemia, 92 patients with 100 limbs werefulfilling the study requirements.Intervention: The patients were randomized into Group A routine completion angiography and Group B withcompletion angiography done on selective basics (failure to advance the embolectomy catheter, inadequate inflowor back flow, extraction of intimal fragments).Design of study: Prospective single center randomized controlled trial, open labelled and the method ofrandomization was by a closed envelop.Main outcome measures: Primary patency rate and limb salvage rates.Results: 92 patients (100 limbs) were enrolled in the trial and were randomized into two equal groups, eachgroup included 50 limbs, mean age for Group A and B were (63.5 12, 60 16), female to male ratio in Group A 1.8and in Group B 1.4, technical success rate was 84% in Group A and 88% in Group B (p 0.564). Using Kaplan Meiercurves, primary patency rate in 12 months was 73% in Group A and 85 % in Group B (p 0.295). Limb salvage ratesin 12 months was 85% in Group A and 92% in Group B (p 0.685).Conclusion: The use of intraoperative angiogram can be used selectively after embolectomy procedures withoutaffecting the long term patency.Keywords: Ischemia; Thrombectomy; Embolectomy; AngiographyIntroductionAcute limb ischemia is one of the important issues in healthcarewith an incidence of 26 cases per 100,000, in-hospital mortality rate of9%, and amputation rates reach up to 30% [1,2]. In 1963, ThomasFogarty by his invention changed the scope of treatment which had agreat impact on limb salvage. However, the route of Fogarty catheter inthe leg arteries is usually unpredictable; the usual passage for thecatheter in a patent arterial tree below the knee is the peroneal artery(90%) followed by the posterior tibial artery (10%) [3]. Theintroduction of endovascular options as a tool was to improve thediagnosis and management of acute limb ischemia [4]. The use ofpercutaneous endovascular techniques in acute limb ischemia such asmechanical thrombectomy or intra-arterial thrombolysis werereported in many studies [5], yet, it failed to show superiority over theopen surgical technique [6]. The endovascular assisted embolectomyAngiol, an open access journalISSN:2329-9495consists of completion angiography, embolectomy under fluoroscopicguidance, embolectomy using over the wire embolectomy catheter, andcorrection of underlying arterial lesions, this combination increasedthe efficacy of surgical embolectomy and decreases amputation rates[7]. Many authors recommend the routine use of completionangiogram after open surgical treatment of acute limb ischemia;however none of the published studies were based on randomizedcontrolled trials [8,9].Aim of workTo compare the efficacy of routine use of completion angiogramafter open embolectomy procedures versus using it on selective basiswith regards to the outcomes in the management of acute lower limbischemia.Volume 6 Issue 4 1000219
Citation:Elshafei A, Mowafy K, Soliman M, Megahed A (2018) Routine versus Selective Angiography after Embolectomy in Acute Lower LimbIschemia: A Prospective Randomized Clinical Trial. Angiol 6: 219. doi:10.4172/2329-9495.1000219Page 2 of 7Patients and methodsType of study: Prospective interventional Randomized ControlledTrial.This Prospective study was conducted on 126 patients with 134limbs attended to Mansoura Emergency Hospital and were diagnosedwith acute limb ischemia. From March 2015 to February 2016, all caseswere tested for eligibility criteria. We included Patients who werediagnosed to have acute lower limb ischemia due to native arterialocclusion Grade I, Grade IIA and Grade IIB based upon Rutherford’sclassification in 2009. We excluded Traumatic or iatrogenic acute limbischemia and Grade III acute ischemia (irreversible) with major tissueloss and major amputation is inevitable, also patients with occludedbypass graft and presented with acute limb ischemia, acute limbischemia due to intra-arterial injection and Patients with renalimpairment (serum creatinine 1.2 mg/dL) or with a history ofcontrast-induced nephropathy were excluded. Finally, 92 patients with100 legs were included in the study and 34 patients were excluded fromthe study as shown in Figure 1.angiography and endovascular intervention on demand according tothe result of completion angiogram that consisted of: embolectomyunder fluoroscopic guidance done through a mobile c-arm unit (BVPulsera; Philips Medical system, Netherlands), and using theEmbolectomy Catheter over a wire (LeMaitre Vascular, Burlington,MA), treatment of stenotic lesion endovascularly using Balloondilatation and stenting (Figure 2).Figure 2: Abnormal angiogram after passage of standardembolectomy 5 French catheter from the right groin withinadequate antegrade flow, angiogram showed filling defects atdistal aorta bilateral iliac arteries, the right figure shows theembolus extracted through bilateral femoral exposure.Group (B): Selective completion angiography group. The Group B(control) underwent surgical embolectomy without routine completionangiography. If the results of the embolectomy were not satisfactory inthe same intraoperative session such as: Failure to advance theembolectomy catheter, or obvious satisfactory inflow or backflow, orextraction of intimal fragments. Those patients underwent diagnosticangiography and according to the result of the angiography, the patientmight receive an endovascular or surgical intervention.Intraarterial thrombolysis using Alteplase was used in residualthrombosis in distal runoff vessels, and to enhance the limb perfusion.The indication of intraoperative thrombolysis was based uponIntraoperative angiogram finding and surgeon judgment.The Surgical procedures which were reserved as bailout solutions incase of failure of endovascular options included: arterialendarterectomy with patch closure, cross femoro-femoral bypass,axillo-uni-femoral or bi-femoral bypass, femro-popliteal etrogradethrombectomy and fasciotomy.Figure 1: CONSORT flow chart.This study received an institutional review board approval (MD/85)and registered on clinicaltrials.gov (NCT03388021), all participantshad their rights to withdraw from the study at any time.Intervention: After obtaining informed written consent includingthe procedure and the possible complications, patients wererandomized by closed envelope method into two equal groups eachgroup included 50 legs.Group (A): Routine completion angiography group. The Group Aunderwent open revascularization followed by completionAngiol, an open access journalISSN:2329-9495OutcomesDefinitions: Technical success: The procedure was consideredtechnically successful when there was an audible flow signal byDoppler over anterior or posterior tibial arteries recording 30 mmHgat ankle level two hours after the procedure.Morbidity: Complications related to the procedure.30 days Mortality: The death rate in the first 30-days postprocedure.Primary patency: The interval between the open procedure and thereintervention due to rethrombosis based on clinical judgment, dupleximaging or CT angiogram.Volume 6 Issue 4 1000219
Citation:Elshafei A, Mowafy K, Soliman M, Megahed A (2018) Routine versus Selective Angiography after Embolectomy in Acute Lower LimbIschemia: A Prospective Randomized Clinical Trial. Angiol 6: 219. doi:10.4172/2329-9495.1000219Page 3 of 7Limb salvage rate: The interval between the open procedure and themajor amputation (either below or above knee amputation).Outcome measures: Primary outcomes: Compare between thecomparative groups according to primary patency and limb salvagerates at 12 months.Secondary outcomes: Compare between the comparative groupsaccording to morbidity and 30-days mortality.Statistical analysisThe two groups were tested for equal distribution as regard todemographics, risk factors, onset of symptoms and level of occlusionby using t-test (t), or Mann-Whitney test (Z) for continuous variablesand Chi-square test (χ2) for binomial variables. The effect of theroutine application of completion angiography were evaluated how itincreased primary patency rate (the period until the native arterybecomes occluded after our first intervention) and limb salvage rate(the period until the patient performs a major amputation) using theKaplan Meir curves for survival analysis and log-rank test for detectionof any significant differences. To reject the null hypothesis theincidence of probability should be less than 5%. All calculations wereperformed using SPSS version 20 (IBM Corp, Armonk, NY).Sample size: Based on the annual admission rate of patients withacute lower limb ischemia who get admitted in our centre where thestudy was conducted (134 patients per year) in one year withconfidence level set at 95%, a minimum sample size of 100 patientsequally divided on the two groups of the study was estimated toachieve a study power of 80% with alpha set at 5%.Method of randomization: Closed envelop method with blockallocation five patients in each group.Immediate resultsTechnical success shown to be 86% in both groups with 84% inGroup A and 88% in Group B with no statistical significance betweenboth groups (p-value 0.564), the rate of complete passage of theembolectomy catheter in each group was 46%, the rate of doingcompletion angiography in Group A was 100% while in Group B 64%(p-value 0.001), the rate of balloon dilatation and stent placement inGroup B were higher than Group A without statistical significance (pvalue 0.134 and 0.558), the rate of embolectomy under fluoroscopicguidance was slightly higher in Group A with no statistical significance(p-value 0.779), and rate of using embolectomy over a wire was equalon both groups. Lytic therapy was significantly higher in Group A thanGroup B (p-value 0.027). Patch repair was significantly higher inGroup B than Group A (p-value 0.041), while the other surgicalinterventions (endarterectomy, infra-popliteal exposure, and bypass)were nonsignificant in both groups, the rate of fasciotomy wasnonsignificant (p-value 00.695) (Table 4).Patient characteristicsGroup AGroup BNo.No%GenderMale (%)1836.00%2142.00%Female (%)3264.00%2958.00%Nature of 3162.00%Aorta36.00%24.00%Group allocationIliac510.00%36.00%All these patients are sorted under randomization procedure into 2groups: Group A, and Group B, patient characteristics for each groupwere as the following Tables 1 and 2.Common Femoral24.00%24.00%Superficial frapopliteal00.00%24.00%Group AGroup BFactorp-valueNumber of limbs5050--Mean age stddeviation63.5 1260 16t 1.2620.21Median onset ofsymptoms (Inter quartilerange IQR)5 days(3-10)5 days(2.75-10)Z .116%Level of occlusionResultsχ2Rutherford gradingGrade I918.00%48.00%Grade IIA2244.00%2550.00%Grade IIB1938.00%2141.00%Table 1: Patient demographics in both groups (continuous variables).Table 2: Patient demographics in both groups (binomial variables).From these previous Tables 1 and 2, we concluded that both groupsare normally distributed with regard to age, sex, the onset ofsymptoms, nature of occlusion, level of occlusion and ischemiaseverity. There was a significant difference as regard to DVT incidenceamong Group B with p-value 0.027 while no significant difference asregard to other risk factors (Table 3).Regarding to mortality rate in the first 30 days, the rate varies from8% in Group B to 16% in Group A with no significant differencebetween the two groups (p-value 0.218), the causes of death in GroupA were: three due to rapid atrial fibrillation, two due to myocardialinfarction, one due to decompensated heart failure, two due tointractable hematuria, and one due to major amputation. While thecauses of death in Group B were: one due to cerebral stroke, one due toreperfusion injury, one after major amputation, and one due topulmonary embolism (Table 5).Angiol, an open access journalISSN:2329-9495Volume 6 Issue 4 1000219
Citation:Elshafei A, Mowafy K, Soliman M, Megahed A (2018) Routine versus Selective Angiography after Embolectomy in Acute Lower LimbIschemia: A Prospective Randomized Clinical Trial. Angiol 6: 219. doi:10.4172/2329-9495.1000219Page 4 of 7Group Aχ2Group Bp-valueEndarterectomy00.00%12.00%1.010.315Fem-fem bypass24.00%00.00%2.0410.153Risk -pop 70.829Interposition 841Axillofemoral opliteal exposure24.00%12.00%0.3440.558Valvular heart .1540.695Cerebral stroke510.00%918.00%1.3290.249Ischemic heart 40.558Congestive heart 0.0780.779Preoperative nant ollagen disease12.00%00.00%1.010.315Previous acute ischemia12.00%24.00%0.3440.558Table 3: Patient risk factors.Technical successGroup AGroup Bχ2p-valueNo.%No.%4284.00%4488.00%0.3320.564Table 4: Immediate results.Group AGroup al infarction225.00%00.00%1.20.273Cardiac arrhythmia337.50%00.00%20.157Cerebral 30.584Hematuria225.00%00.00%1.20.273Pulmonary embolism00.00%125.00%2.1820.1430 days mortality rateCause of mortalityTable 5: 30 days mortality in both groups.Passage of embolectomy catheter80-61 cm2346.00%2346.00%--60-51 cm1224.00%1428.00%--50-31 cm1020.00%1122.00%1.4870.68530-0 cm510.00%24.00%--Completion angiography50100.00%3264.00%21.951 oroscopic guidance16.00%714.00%0.0780.779Fogarty over the wire714.00%714.00%01Balloon dilatation714.00%1326.00%2.250.134Stent placement12.00%24.00%0.3440.558Lytic .041*The rate of cardiac complications (arrhythmia, myocardialinfarction, and decompensated heart failure) was more in Group A butdidn’t reach statistical significance (p-value 0.05), cerebral strokeswere noticed in two patients in Group B but with no significantdifference, the incidence of hematuria was 6% in Group A (pvalue 0.079), a case of reperfusion syndrome reported in Group B andwas the cause of death in this patient, the contrast-inducednephropathy didn’t develop at any group (Figures 3 and 4).As regard to local complications; postoperative hematomaincidence, surgical site infection, and compartmental syndrome weremore in Group A with mo statistical significance (p-values 0.307,0.307, 0.695), while rate of arterial perforation and pseudoaneurysmformation were more in Group B with no statistical significance (pvalue 0.646), there were no cases reported with postoperative bleedingor arteriovenous fistula (Table 6).Adjunct surgical interventionPatch repair0Angiol, an open access journalISSN:2329-9495Volume 6 Issue 4 1000219
Citation:Elshafei A, Mowafy K, Soliman M, Megahed A (2018) Routine versus Selective Angiography after Embolectomy in Acute Lower LimbIschemia: A Prospective Randomized Clinical Trial. Angiol 6: 219. doi:10.4172/2329-9495.1000219Page 5 of 7Figure 3: Completion angiogram revealed extravasation of the dyeoutside the tibioperoneal trunk, patient developed compartmentalsyndrome on table, immediate exposure over tibioperoneal trunkand direct repair of small hole and release of four leg compartmentwere done.Figure 4: Completion angiogram revealed arterial perforation andpseudoaneurysm formation at the middle third of posterior tibialartery.Group AGroup Bχ2p-valueNo.%No.%Cardiac arrhythmia12.00%00.00%1.010.315Myocardial infarction24.00%00.00%2.0410.153Cardiac failure24.00%00.00%2.0410.153Cerebral stroke00.00%24.00%2.0410.153Reperfusion syndrome00.00%12.00%1.010.315Pulmonary 3.0930.079Contrast induced 0.307Surgical site bleeding00.00%00.00%--Surgical site infection36.00%12.00%1.0420.307Arterial perforation (Figure 5)24.00%36.00%0.2110.646Compartmental syndrome (Figure 4)48.00%36.00%0.1540.695Arteriovenous fistula00.00%00.00%--MorbidityTable 6: Morbidity rates in both groups.Angiol, an open access journalISSN:2329-9495Volume 6 Issue 4 1000219
Citation:Elshafei A, Mowafy K, Soliman M, Megahed A (2018) Routine versus Selective Angiography after Embolectomy in Acute Lower LimbIschemia: A Prospective Randomized Clinical Trial. Angiol 6: 219. doi:10.4172/2329-9495.1000219Page 6 of 7Late resultsPatients were followed up for 12 months in each group, follow-upwas based on clinical examination to exclude any signs of acuteischemia with measurement of ankle peak systolic pressure, if less than30mmHg a decision for reintervention was made, if there was nonviable limb a decision for amputation was made. Long-term resultsdivided into primary patency of arterial tree after embolectomy andlimb salvage rates (Table 7).Group A (N 50)applied it showed no significant difference between two groups asregard to Limb salvage rates at 12 months which were 85% in Group Aand 92% in Group B (Figure 6 and Table 9).Group B (N 50)No%No%Completed 12 months of follow-up2448%2550%Died during follow-up1326%612%Lost during follow-up1326%1938%Table 7: Patient status during 12 months of follow-up.Primary patencyUsing the Kaplan Meier survival analysis the two groups were testedfor any significant to reject the null hypothesis, when log-rank testapplied it showed no significant difference between two groups asregard to primary patency rates at 12 months which were 73% inGroup A and 85% in Group B (Figure 5 and Table 8).Figure 6: Kaplan Meier survival analysis curve.Log Rank 0.685Table 9: Log-rank test for comparison of limb salvage between bothgroups.DiscussionThe use of fluoroscopic imaging as a visual feedback forembolectomy to increase the effectiveness of the procedures was firstreported by Parsons and his colleagues using canine models in 1996,and reported by Lipsitz and Veith in humans in 2001 [10,11]. Thispoint of research based on many studies that used the intraoperativediagnostic procedures like conventional angiography, angioscope, andintravascular ultrasound found residual thrombosis attached to thearterial walls after embolectomy [12,13], this made many authorsconclude that routine angiography should be done after openrevascularization [14-16].Figure 5: Kaplan Meier survival analysis curve.Log Rank 0.295Table 8: Log-rank test for comparison of primary patency betweenboth groups.Limb salvage ratesUsing the Kaplan Meier survival analysis the two groups were testedfor any significant to reject the null hypothesis, when log-rank testAngiol, an open access journalISSN:2329-9495In 2010, Zaraca and his colleagues reported on 380 cases of acuteischemia of the lower limb went for embolectomy in the past 12 years,intraoperative angiogram was done from 1991 to 1997 on selectivebasis (inadequate backflow, failure to advance the embolectomycatheter distally) including 216 cases (Group A), and were done from1998 to 2003 routinely in 164 cases (Group B), both groups wereequally distributed regarding age, gender and risk factors, transluminalangioplasty was done in 7.2% of Group A while was done in 17.2% inGroup B, after 2 years of follow-up, the completion angiogram lead tosignificant increase in the primary patency in Group B when it wasused routinely (P 0.001), but no significant difference was detectedbetween both groups in terms of limb salvage (P 0.72) [16].In our study we reported on 100 cases went for embolectomy in oneyear, intraoperative angiogram was done on routine basis in 50 casesVolume 6 Issue 4 1000219
Citation:Elshafei A, Mowafy K, Soliman M, Megahed A (2018) Routine versus Selective Angiography after Embolectomy in Acute Lower LimbIschemia: A Prospective Randomized Clinical Trial. Angiol 6: 219. doi:10.4172/2329-9495.1000219Page 7 of 7(Group A) and selectively (inadequate backflow, failure to advance theembolectomy catheter distally, extraction of intimal segments) in 50cases (Group B), both groups in spite of randomization were equallydistributed according to age, gender and risk factors except for theincidence of deep vein thrombosis which was significantly higher inGroup B (P 0.027), angioplasty was done in 26% of cases on Group Band 14% of the cases in Group A, after 12 months of follow-up, therewas no statistical significance between both groups as related toprimary patency (P 0.295) and limb salvage (P 0.685).This prospective randomized clinical trial is an important trialdealing with limb salvage in acute limb ischemia, its design allowed toanswer one of the important questions facing the vascular surgeon inoperative theatre after doing open embolectomy, do we need aconfirmatory angiogram after each case or better save this option forselected cases. The design of the study allowed the use of endovasculartechniques in both groups whenever needed, based on the result of theangiogram. The randomization process led to exclude any selectionbias, without affecting the ethical consideration for preventing any ofthe two groups from getting the benefit of endovascular optionwhenever needed.Technical success of our center compared to our reporting showed86% in both groups and this was attributed to the usage ofendovascular techniques besides the use of completion angiogram ascompared to previous studies, taking into consideration that the onsetof symptoms was reported as 86% of the patient were presented morethan 24 hours and median onset of 5 days, this has turned many casesinto challenging situations and led to increase the perioperativemortality that ranged from 8% to 16% in our study, while most reportsranged from 5% to 12% [1,17].Although the outcomes of both modalities were not significant, thehigher rate of patency was in the group that used the angiogram onselected bases, and this seemed to be a cost-effective protocol incountries with limited resources; however, this outcome may be relatedto the small sample size, the high mortality rate, or the high number ofpatients missed during follow-up, hopefully in the near future furtherstudies may reveal this truth clearly.In our study the results showed patency and limb salvage rates quitesimilar to the previous studies despite the lack of logistics and the latepresentation of some cases, a lot of efforts are being made in our centerto increase the follow-up efficacy, provide healthcare resources andraise the medical awareness for acute limb ischemia in the community.We recommend recruitment of more patients, raising research fundsand collaborating with other centers to increase the level of evidence inthe future studies.ConclusionCompletion angiography after open revascularization is a usefulmodality and improves the outcomes of acute limb ischemiamanagement; however, it can be done on selective criteria and notroutinely without affecting the long term patency.Angiol, an open access 0.11.12.13.14.15.16.17.Baril DT, Ghosh K, Rosen AB (2014) Trends in the incidence, treatment,and outcomes of acute lower extremity ischemia in the United StatesMedicare population. Journal of Vascular Surgery, 60: 669- 677.e2.Dormandy J, Heeck L, Vig S (1999) Acute limb ischemia. Seminars inVascular Surgery 12: 148-153.Gwynn BR, Shearman CP, Simms MH (1987) The anatomical basis forthe route taken by Fogarty catheters in the lower leg. European Journal ofVascular Surgery 1: 129-132.Sadaghianloo N, Jean-Baptiste E, Declemy S, Mousnier A, Brizzi S, et al.(2013) Percutaneous angioplasty of long tibial occlusions in critical limbischemia. Annals of Vascular Surgery 27: 894-903.Ouriel K, Veith FJ, Sasahara AA (1996) Thrombolysis or peripheralarterial surgery: phase I results. TOPAS Investigators. Journal of VascularSurgery 23: 64-75.Rutherford RB (2009) Clinical staging of acute limb ischemia as the basisfor choice of revascularization method: when and how to intervene.Seminars in Vascular Surgery 22: 5-9.Ouriel K (2003) Endovascular techniques in the treatment of acute limbischemia: thrombolytic agents, trials, and percutaneous mechanicalthrombectomy techniques. Seminars in Vascular Surgery 16: 270-279.De Donato G, Setacci F, Sirignano P, Galzerano G, Massaroni R, Setacci C(2014) The combination of surgical embolectomy and endovasculartechniques may improve outcomes of patients with acute lower limbischemia. Journal of Vascular Surgery 59: 729-736.Argyriou C, Georgakarakos E, Georgiadis GS, Antoniou GA,Schoretsanitis N, et al. (2014) Hybrid Revascularization Procedures inAcute Limb Ischemia. Annals of Vascular Surgery 28: 1456-1462.Parsons RE, Marin ML, Veith FJ, Sanchez LA, Lyon RT, et al. (1996)Fluoroscopically assisted thromboembolectomy: an improved method fortreating acute arterial occlusions. Annals of Vascular Surgery 10: 201-210.Lipsitz EC, Veith FJ, Wain RA (2003) Digital fluoroscopy as a valuableadjunct to open vascular operations. Seminars in Vascular Surgery 16:280-290.Bowald S, Eriksson I, Fagerberg S (1978) Intraoperative angiography inarterial surgery. Acta Chirurgica Scandinavica 144: 463-469.White GH, White RA, Kopchok GE, Wilson SE (1988) Angioscopicthromboembolectomy: preliminary observations with a recent technique.Journal of Vascular Surgery 7: 318-325.Ebner H, Zaraca F, Randone B (2004) The role of intraoperativeangiography in arterial thromboembolectomy for non-traumatic acuteupper limb ischaemia. Chirurgia Italiana 56: 345-350.O’Connell JB, Quiñones-Baldrich WJ (2009) Proper evaluation andmanagement of acute embolic versus thrombotic limb ischemia. Seminarsin Vascular Surgery 22: 10-16.Zaraca F, Stringari C, Ebner JA, Ebner H (2010) Routine versus selectiveuse of intraoperative angiography during thromboembolectomy for acutelower limb ischemia: analysis of outcomes. Annals of Vascular Surgery 24:621-627.Aune S, Trippestad A (1998) Operative Mortality and Long-term Survivalof Patients Operated on for Acute Lower Limb Ischaemia. EuropeanJournal of Vascular and Endovascular Surgery 15: 143-146.Volume 6 Issue 4 1000219
after open embolectomy procedures versus using it on selective basis with regards to the outcomes in the management of acute lower limb ischemia. A n g i o l o g y :O pe n A c c e s s ISSN: 2329-9495 Angiology: Open Access Elshafei et al., Angiol 2018, 6:4 DOI: 10.4172/2329-9495.1000219 Research Article Open Access Angiol, an open access .
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