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Advances in Surgery Sep 2022Acute limb ischemia (ALI) is a vascular emergency associated with high rates of limb loss and mortality. Management of these patients is challenging given the severe... (Review)
Review
Acute limb ischemia (ALI) is a vascular emergency associated with high rates of limb loss and mortality. Management of these patients is challenging given the severe systemic illness resulting from tissue ischemia and the high incidence of preexisting comorbid conditions and underlying peripheral arterial disease. Expeditious diagnosis, anticoagulation, and revascularization are of utmost importance in reducing morbidity. Revascularization may be accomplished using open, endovascular, or hybrid techniques. Approach to revascularization depends on the severity of ischemia, location of occlusion, cause, chance of recovery, comorbidities, and available resources.
Topics: Arterial Occlusive Diseases; Humans; Ischemia; Peripheral Arterial Disease; Risk Factors; Treatment Outcome
PubMed: 36096573
DOI: 10.1016/j.yasu.2022.03.004 -
ACS Nano 2015Peripheral vascular disease (PVD) is one of the most prevalent vascular diseases in the U.S. afflicting an estimated 8 million people. Obstruction of peripheral arteries... (Review)
Review
Peripheral vascular disease (PVD) is one of the most prevalent vascular diseases in the U.S. afflicting an estimated 8 million people. Obstruction of peripheral arteries leads to insufficient nutrients and oxygen supply to extremities, which, if not treated properly, can potentially give rise to a severe condition called critical limb ischemia (CLI). CLI is associated with extremely high morbidities and mortalities. Conventional treatments such as angioplasty, atherectomy, stent implantation and bypass surgery have achieved some success in treating localized macrovascular disease but are limited by their invasiveness. An emerging alternative is the use of growth factor (delivered as genes or proteins) and cell therapy for PVD treatment. By delivering growth factors or cells to the ischemic tissue, one can stimulate the regeneration of functional vasculature network locally, re-perfuse the ischemic tissue, and thus salvage the limb. Here we review recent advance in nanomaterials, and discuss how their application can improve and facilitate growth factor or cell therapies. Specifically, nanoparticles (NPs) can serve as drug carrier and target to ischemic tissues and achieve localized and sustained release of pro-angiogenic proteins. As nonviral vectors, NPs can greatly enhance the transfection of target cells with pro-angiogenic genes with relatively fewer safety concern. Further, NPs may also be used in combination with cell therapy to enhance cell retention, cell survival and secretion of angiogenic factors. Lastly, nano/micro fibrous vascular grafts can be engineered to better mimic the structure and composition of native vessels, and hopefully overcome many complications/limitations associated with conventional synthetic grafts.
Topics: Animals; Cell- and Tissue-Based Therapy; Extremities; Humans; Ischemia; Nanomedicine; Peripheral Vascular Diseases; Tissue Engineering
PubMed: 25844518
DOI: 10.1021/nn507269g -
Journal of the American College of... Nov 2016Critical limb ischemia (CLI), the most advanced form of peripheral artery disease, is associated with significant morbidity, mortality, and health care resource... (Review)
Review
Critical limb ischemia (CLI), the most advanced form of peripheral artery disease, is associated with significant morbidity, mortality, and health care resource utilization. It is also associated with physical, as well as psychosocial, consequences such as amputation and depression. Importantly, after a major amputation, patients are at heightened risk of amputation on the contralateral leg. However, despite the technological advances to manage CLI with minimally invasive technologies, this condition often remains untreated, with significant disparities in revascularization and amputation rates according to race, socioeconomic status, and geographic region. Care remains disparate across medical specialties in this rapidly evolving field. Many challenges persist, including appropriate reimbursement for treating complex patients with difficult anatomy. This paper provides a comprehensive summary that includes diagnostic assessment and analysis, endovascular versus open surgical treatment, regenerative and adjunctive therapies, and other important aspects of CLI.
Topics: Algorithms; Critical Illness; Humans; Ischemia; Leg; Peripheral Arterial Disease; Vascular Surgical Procedures
PubMed: 27692726
DOI: 10.1016/j.jacc.2016.04.071 -
JACC. Cardiovascular Interventions Oct 2020
Topics: Humans; Ischemia; Paclitaxel; Pharmaceutical Preparations; Popliteal Artery; Treatment Outcome
PubMed: 32950414
DOI: 10.1016/j.jcin.2020.07.036 -
Vascular Health and Risk Management 2018Critical limb ischemia (CLI) is considered the most severe pattern of peripheral artery disease. It is defined by the presence of chronic ischemic rest pain, ulceration... (Review)
Review
Critical limb ischemia (CLI) is considered the most severe pattern of peripheral artery disease. It is defined by the presence of chronic ischemic rest pain, ulceration or gangrene attributable to the occlusion of peripheral arterial vessels. It is associated with a high risk of major amputation, cardiovascular events and death. In this review, we presented a complete overview about physiopathology, diagnosis and holistic management of CLI. Revascularization is the first-line treatment, but several challenging cases are not treatable by conventional techniques. Unconventional techniques for the treatment of complex below-the-knee arterial disease are described. Furthermore, the state-of-the-art on gene and cell therapy for the treatment of no-option patients is reported.
Topics: Angiography; Clinical Decision-Making; Comorbidity; Critical Illness; Humans; Ischemia; Peripheral Arterial Disease; Predictive Value of Tests; Regional Blood Flow; Risk Factors; Treatment Outcome
PubMed: 29731636
DOI: 10.2147/VHRM.S125065 -
Angiology Jul 2018Critical limb ischemia (CLI) is the most advanced form of peripheral artery disease. It is associated with significant morbidity and mortality and high management costs.... (Review)
Review
Critical limb ischemia (CLI) is the most advanced form of peripheral artery disease. It is associated with significant morbidity and mortality and high management costs. It carries a high risk of amputation and local infection. Moreover, cardiovascular complications remain a major concern. Although it is a well-known entity and new technological and therapeutic advances have been made, this condition remains poorly addressed, with significantly heterogeneous management, especially in nonexperienced centers. This review, from a third-level dedicated inpatient and outpatient cardioangiology structure, aims to provide an updated summary on the topic of CLI of its complexity, encompassing epidemiological, social, economical and, in particular, diagnostic/imaging issues, together with potential therapeutic strategies (medical, endovascular, and surgical), including the evaluation of cardiovascular risk factors, the diagnosis, and treatment together with prognostic stratification.
Topics: Humans; Ischemia; Lower Extremity; Peripheral Arterial Disease
PubMed: 29161885
DOI: 10.1177/0003319717739387 -
Vascular and Endovascular Surgery Nov 2018Retrograde pedal access is a technique utilized with increasing frequency by many interventionists to address patients with advanced multilevel peripheral artery disease...
Retrograde pedal access is a technique utilized with increasing frequency by many interventionists to address patients with advanced multilevel peripheral artery disease and significant comorbidities. This approach to revascularization is being used both in patients who fail traditional antegrade access and in some patients thought to be poor candidates for antegrade approach. However, the lack of randomized controlled trial data, or long-term results, coupled with the associated potential risks including dissection, spasm, and thrombosis have rendered retrograde pedal access a controversial topic. This article details the pros and cons associated with the debate surrounding retrograde pedal access and highlights the current literature and remaining questions regarding outcomes of this technique.
Topics: Clinical Decision-Making; Critical Illness; Endovascular Procedures; Humans; Ischemia; Lower Extremity; Patient Selection; Peripheral Arterial Disease; Risk Factors; Treatment Outcome
PubMed: 29932023
DOI: 10.1177/1538574418780055 -
Seminars in Vascular Surgery Jun 2023Acute limb ischemia (ALI) can be a devastating clinical emergency with potentially limb- or life-threatening consequences. It is defined as a quickly developing or... (Review)
Review
Acute limb ischemia (ALI) can be a devastating clinical emergency with potentially limb- or life-threatening consequences. It is defined as a quickly developing or sudden decrease in limb perfusion producing new or worsening symptoms and signs, often threatening limb viability. ALI is commonly related to an acute arterial occlusion. Rarely, extensive venous occlusion can lead to upper and lower extremities ischemia (ie, phlegmasia). The incidence of acute peripheral arterial occlusion causing ALI is approximately 1.5 cases per 10,000 people per year. The clinical presentation depends on the etiology and whether the patient has underlying peripheral artery disease. Except for traumas, the most common etiologies are embolic or thrombotic events. Peripheral embolism, likely related to embolic heart disease, is the most common cause of acute upper extremity ischemia. However, an acute thrombotic event may occur in native arteries, at the site of a pre-existing atherosclerotic plaque, or as a failure of previous vascular interventions. The presence of an aneurysm may predispose to ALI for both embolic and thrombotic mechanisms. Immediate diagnosis, accurate assessment of limb viability, and prompt intervention, when needed, play important roles in salvaging the affected limb and preventing major amputation. Severity of symptoms is usually dependent on the amount of surrounding arterial collateralization, which may often reflect a pre-existing chronic vascular disease. For this reason, early recognition of the underlying etiology is crucial for choice of best management and definitely for treatment success. Any error in the initial evaluation may negatively affect the functional prognosis of the limb and endanger the patient's life. The aim of this article was to discuss diagnosis, etiology, pathophysiology, and treatment of patients with acute ischemia of the upper and lower limbs.
Topics: Humans; Lower Extremity; Ischemia; Arterial Occlusive Diseases; Thrombosis; Embolism; Peripheral Arterial Disease; Treatment Outcome; Acute Disease; Retrospective Studies
PubMed: 37330235
DOI: 10.1053/j.semvascsurg.2023.04.006 -
Cardiovascular Research Mar 2019Current treatment of ischaemic vascular diseases such as coronary and peripheral artery disease includes angioplasty and bypass grafting, as well as lipid lowering... (Review)
Review
Current treatment of ischaemic vascular diseases such as coronary and peripheral artery disease includes angioplasty and bypass grafting, as well as lipid lowering therapies and control of other cardiovascular risk factors. Numerous members of the tumour necrosis factor superfamily (TNFSF) have recently shown emerging roles in both the protection and progression of such diseases. Understanding the role TNFSF members play in ischaemic vascular disease may provide insight into the development of novel therapeutics to prevent or treat diseases relating to atherosclerosis and ischaemia. This review summarizes the most recent findings relating to TNFSF members and the mechanisms that precede ischaemic vascular disease progression, particularly endothelial dysfunction, chronic inflammation, and atherosclerotic plaque development. This review also explores recent translational research on the role of TNFSF therapies in cardiovascular disease.
Topics: Animals; Arteries; CD40 Ligand; Cytokine TWEAK; Humans; Ischemia; Receptors, Tumor Necrosis Factor; Signal Transduction; TNF-Related Apoptosis-Inducing Ligand; Tumor Necrosis Factor Inhibitors; Tumor Necrosis Factor-alpha; Tumor Necrosis Factors; Vascular Diseases
PubMed: 30816914
DOI: 10.1093/cvr/cvz042 -
Cardiology Clinics Feb 2015Critical limb ischemia (CLI), the most advanced form of peripheral artery disease (PAD), carries grave implications with regard to morbidity and mortality. Within 1 year... (Review)
Review
Critical limb ischemia (CLI), the most advanced form of peripheral artery disease (PAD), carries grave implications with regard to morbidity and mortality. Within 1 year of CLI diagnosis, 40% to 50% of diabetics will experience an amputation, and 20% to 25% will die. Management is optimally directed at increasing blood flow to the affected extremity to relieve rest pain, heal ischemic ulcerations, avoid limb loss, and prevent cardiovascular events. This management is achieved by guideline-directed medical therapy and risk factor modification, whereas the mainstay of therapy remains revascularization by endovascular or surgical means for patients who are deemed potential candidates.
Topics: Aged; Cross-Sectional Studies; Female; Humans; Ischemia; Leg; Male; Middle Aged; Prognosis; Referral and Consultation; United States
PubMed: 25439329
DOI: 10.1016/j.ccl.2014.09.008