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Journal of Vascular Surgery Jun 2019Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on...
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
Topics: Cardiac Imaging Techniques; Cardiology; Chronic Disease; Consensus; Evidence-Based Medicine; Heart Function Tests; Humans; Ischemia; Peripheral Arterial Disease; Predictive Value of Tests; Risk Factors; Terminology as Topic; Treatment Outcome
PubMed: 31159978
DOI: 10.1016/j.jvs.2019.02.016 -
Critical Care (London, England) Jul 2019Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is an increasingly adopted life-saving mechanical circulatory support for a number of potentially reversible... (Review)
Review
Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is an increasingly adopted life-saving mechanical circulatory support for a number of potentially reversible or treatable cardiac diseases. It is also started as a bridge-to-transplantation/ventricular assist device in the case of unrecoverable cardiac or cardio-respiratory illness. In recent years, principally for non-post-cardiotomy shock, peripheral cannulation using the femoral vessels has been the approach of choice because it does not need the chest opening, can be quickly established, can be applied percutaneously, and is less likely to cause bleeding and infections than central cannulation. Peripheral ECMO, however, is characterized by a higher rate of vascular complications. The mechanisms of such adverse events are often multifactorial, including suboptimal arterial perfusion and hemodynamic instability due to the underlying disease, peripheral vascular disease, and placement of cannulas that nearly occlude the vessel. The effect of femoral artery damage and/or significant reduced limb perfusion can be devastating because limb ischemia can lead to compartment syndrome, requiring fasciotomy and, occasionally, even limb amputation, thereby negatively impacting hospital stay, long-term functional outcomes, and survival. Data on this topic are highly fragmentary, and there are no clear-cut recommendations. Accordingly, the strategies adopted to cope with this complication vary a great deal, ranging from preventive placement of antegrade distal perfusion cannulas to rescue interventions and vascular surgery after the complication has manifested.This review aims to provide a comprehensive overview of limb ischemia during femoral cannulation for VA-ECMO in adults, focusing on incidence, tools for early diagnosis, risk factors, and preventive and treating strategies.
Topics: Catheterization, Peripheral; Extracorporeal Membrane Oxygenation; Extremities; Humans; Incidence; Ischemia; Risk Factors
PubMed: 31362770
DOI: 10.1186/s13054-019-2541-3 -
British Journal of Hospital Medicine... May 2022Aneurysms are associated with significant complications if not diagnosed and managed appropriately. Popliteal arterial aneurysms are the most common peripheral aneurysm,...
Aneurysms are associated with significant complications if not diagnosed and managed appropriately. Popliteal arterial aneurysms are the most common peripheral aneurysm, and can cause pain, nerve compression, ischaemia and limb loss. Vascular surgery is an emerging specialty under the remit of general surgery, with the primary objectives of preventing death and limb loss. This article summarises the epidemiology, investigation and management of popliteal arterial aneurysms for vascular and non-vascular trainees.
Topics: Aneurysm; Humans; Ischemia; Popliteal Artery
PubMed: 35653317
DOI: 10.12968/hmed.2021.0572 -
Lancet (London, England) May 2023Chronic limb-threatening ischaemia is the severest manifestation of peripheral arterial disease and presents with ischaemic pain at rest or tissue loss (ulceration,... (Randomized Controlled Trial)
Randomized Controlled Trial
A vein bypass first versus a best endovascular treatment first revascularisation strategy for patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal revascularisation procedure to restore limb perfusion (BASIL-2):...
BACKGROUND
Chronic limb-threatening ischaemia is the severest manifestation of peripheral arterial disease and presents with ischaemic pain at rest or tissue loss (ulceration, gangrene, or both), or both. We compared the effectiveness of a vein bypass first with a best endovascular treatment first revascularisation strategy in terms of preventing major amputation and death in patients with chronic limb threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal, revascularisation procedure to restore limb perfusion.
METHODS
Bypass versus Angioplasty for Severe Ischaemia of the Leg (BASIL)-2 was an open-label, pragmatic, multicentre, phase 3, randomised trial done at 41 vascular surgery units in the UK (n=39), Sweden (n=1), and Denmark (n=1). Eligible patients were those who presented to hospital-based vascular surgery units with chronic limb-threatening ischaemia due to atherosclerotic disease and who required an infra-popliteal, with or without an additional more proximal infra-inguinal, revascularisation procedure to restore limb perfusion. Participants were randomly assigned (1:1) to receive either vein bypass (vein bypass group) or best endovascular treatment (best endovascular treatment group) as their first revascularisation procedure through a secure online randomisation system. Participants were excluded if they had ischaemic pain or tissue loss considered not to be primarily due to atherosclerotic peripheral artery disease. Most vein bypasses used the great saphenous vein and originated from the common or superficial femoral arteries. Most endovascular interventions comprised plain balloon angioplasty with selective use of plain or drug eluting stents. Participants were followed up for a minimum of 2 years. Data were collected locally at participating centres. In England, Wales, and Sweden, centralised databases were used to collect information on amputations and deaths. Data were analysed centrally at the Birmingham Clinical Trials Unit. The primary outcome was amputation-free survival defined as time to first major (above the ankle) amputation or death from any cause measured in the intention-to-treat population. Safety was assessed by monitoring serious adverse events up to 30-days after first revascularisation. The trial is registered with the ISRCTN registry, ISRCTN27728689.
FINDINGS
Between July 22, 2014, and Nov 30, 2020, 345 participants (65 [19%] women and 280 [81%] men; median age 72·5 years [62·7-79·3]) with chronic limb-threatening ischaemia were enrolled in the trial and randomly assigned: 172 (50%) to the vein bypass group and 173 (50%) to the best endovascular treatment group. Major amputation or death occurred in 108 (63%) of 172 patients in the vein bypass group and 92 (53%) of 173 patients in the best endovascular treatment group (adjusted hazard ratio [HR] 1·35 [95% CI 1·02-1·80]; p=0·037). 91 (53%) of 172 patients in the vein bypass group and 77 (45%) of 173 patients in the best endovascular treatment group died (adjusted HR 1·37 [95% CI 1·00-1·87]). In both groups the most common causes of morbidity and death, including that occurring within 30 days of their first revascularisation, were cardiovascular (61 deaths in the vein bypass group and 49 in the best endovascular treatment group) and respiratory events (25 deaths in the vein bypass group and 23 in the best endovascular treatment group; number of cardiovascular and respiratory deaths were not mutually exclusive).
INTERPRETATION
In the BASIL-2 trial, a best endovascular treatment first revascularisation strategy was associated with a better amputation-free survival, which was largely driven by fewer deaths in the best endovascular treatment group. These data suggest that more patients with chronic limb-threatening ischaemia who required an infra-popliteal, with or without an additional more proximal infra-inguinal, revascularisation procedure to restore limb perfusion should be considered for a best endovascular treatment first revascularisation strategy.
FUNDING
UK National Institute of Health Research Health Technology Programme.
Topics: Male; Humans; Female; Aged; Chronic Limb-Threatening Ischemia; Ocimum basilicum; Ischemia; Angioplasty, Balloon, Coronary; Peripheral Arterial Disease; Risk Factors; Perfusion; Pain; Treatment Outcome
PubMed: 37116524
DOI: 10.1016/S0140-6736(23)00462-2 -
Techniques in Vascular and... Jun 2016
Topics: Cardiovascular Agents; Critical Illness; Endovascular Procedures; Humans; Ischemia; Lower Extremity; Peripheral Arterial Disease; Treatment Outcome; Vascular Surgical Procedures
PubMed: 27423988
DOI: 10.1053/j.tvir.2016.05.003 -
Revue Medicale de Liege May 2018Despite major advances in the contemporary management of peripheral arterial occlusive disease, acute ischemia of the lower limb is still characterized by an important... (Review)
Review
Despite major advances in the contemporary management of peripheral arterial occlusive disease, acute ischemia of the lower limb is still characterized by an important morbidity, limb threat, and mortality, and continues to pose a challenge to the vascular surgeon. Ageing of the population increases the prevalence of acute lower limb ischemia. The two principal etiologies of acute ischemia of the lower limbs are arterial embolism and in situ thrombosis of an atherosclerotic artery or of a bypass graft. Popliteal aneurysm thrombosis and vascular trauma are less common causes of severe limb ischemia. Prompt recognition and treatment of acute limb ischemia in an urgent setting are crucial, in order to shorten as much as possible the duration of the ischemia. This paper highlights diagnostic work-up (staging of the severity of ischemia) and appropriate management of acute ischemia of the lower limb. Different procedures of revascularization (operative clot removal, catheter-directed thrombolysis, bypass grafting are evaluated and their outcome results are compared.
Topics: Acute Disease; Amputation, Surgical; Humans; Ischemia; Lower Extremity; Peripheral Vascular Diseases
PubMed: 29926571
DOI: No ID Found -
Advances in Surgery Sep 2023Management of acute limb ischemia is complex and time sensitive, and delays in diagnosis and treatment may lead to irreversible tissue damage. Current data challenge the... (Review)
Review
Management of acute limb ischemia is complex and time sensitive, and delays in diagnosis and treatment may lead to irreversible tissue damage. Current data challenge the commonly accepted 6-hour ischemic threshold for acute limb ischemia, although variations in practice remain. Patients with chronic peripheral artery disease may tolerate longer ischemia time due to presence of collateral circulation. Here the authors discuss the presentation, workup, management, and postoperative care of patients with acute limb ischemia, with a focus on how management is altered depending on the duration and degree of ischemia.
Topics: Humans; Limb Salvage; Treatment Outcome; Lower Extremity; Peripheral Arterial Disease; Ischemia; Retrospective Studies; Risk Factors
PubMed: 37536862
DOI: 10.1016/j.yasu.2023.05.003 -
The Surgical Clinics of North America Aug 2023As the number of patients affected by peripheral arterial disease continues to increase, new technical approaches and devices have been developed to provide effective... (Review)
Review
As the number of patients affected by peripheral arterial disease continues to increase, new technical approaches and devices have been developed to provide effective and durable treatment options that will lead to improved outcomes. While the mainstay of endovascular intervention remains mostly balloon-based, several innovative techniques and technologies are in development that may provide new solutions. This review highlights recent endovascular advancements in the management of chronic limb-threatening ischemia and additional adjunctive devices that are needed to improve lesion patency, reduce the need for reintervention, and lead to better patient-centered functional outcomes.
Topics: Humans; Limb Salvage; Treatment Outcome; Endovascular Procedures; Peripheral Arterial Disease; Ischemia; Risk Factors
PubMed: 37455037
DOI: 10.1016/j.suc.2023.05.002 -
The Journal of Cardiovascular Surgery Aug 2023Acute limb ischemia (ALI) is an emergency situation requiring rapid diagnosis and treatment. Although the traditional treating strategy for ALI includes open surgery,... (Review)
Review
Acute limb ischemia (ALI) is an emergency situation requiring rapid diagnosis and treatment. Although the traditional treating strategy for ALI includes open surgery, novel endovascular techniques have been introduced during the last decade. Additionally, many new cases of ALI have been reported due to infection by the SARS-CoV-2 virus. The aim of this study was to present an updated overview of characteristics, diagnosis, and current treating strategies of patients with ALI.
Topics: Humans; Limb Salvage; Treatment Outcome; Lower Extremity; Risk Factors; COVID-19; SARS-CoV-2; Peripheral Vascular Diseases; Endovascular Procedures; Ischemia; Acute Disease; Retrospective Studies
PubMed: 36762508
DOI: 10.23736/S0021-9509.22.12536-X -
The Surgical Clinics of North America Aug 2023The original description of the lower extremity bypass (LEB) provided surgeons with a reliable method of limb revascularization. The tenets of the operation have formed... (Review)
Review
The original description of the lower extremity bypass (LEB) provided surgeons with a reliable method of limb revascularization. The tenets of the operation have formed the foundation for the advances of surgical care. A careful evaluation of the chronic limb-threatening ischemia patient due to the numerous comorbid conditions is paramount to obtain the best possible outcomes. Use of all adjuncts including judicious target vessels control, completion imaging, and vein harvesting techniques to ensure optimal outcomes because a functioning LEB remains a key to successful limb salvage.
Topics: Humans; Ischemia; Risk Factors; Reoperation; Retrospective Studies; Lower Extremity; Treatment Outcome; Peripheral Arterial Disease; Saphenous Vein
PubMed: 37455036
DOI: 10.1016/j.suc.2023.04.014