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JAMA Surgery Nov 2016Chronic critical limb ischemia, marked by intractable lower extremity ischemic rest pain and tissue loss, is a highly morbid condition that leads to the loss of... (Review)
Review
IMPORTANCE
Chronic critical limb ischemia, marked by intractable lower extremity ischemic rest pain and tissue loss, is a highly morbid condition that leads to the loss of ambulation and decreased quality of life. It is associated with a high risk of limb loss and mortality and presents a significant economic burden to society.
OBJECTIVE
To review the current state of epidemiology, pathophysiology, diagnosis, and treatment of critical limb ischemia.
EVIDENCE REVIEW
An extensive literature search of the subject matter was conducted on material published in English between 1980 and 2016; both landmark and recently published articles were evaluated. Articles were reviewed if they included the terms critical limb ischemia, ischemic rest pain, gangrene, or extremity ulcers.
FINDINGS
Critical limb ischemia represents the end stage of peripheral arterial disease. Because peripheral arterial disease is most commonly caused by atherosclerosis, critical limb ischemia is heavily associated with smoking and diabetes. Revascularization is the cornerstone of therapy to prevent limb amputation, and both open vascular surgery and endovascular therapy play a key role in the treatment of patients with critical limb ischemia. However, few scientific data are available to identify the optimal revascularization strategy, which has led to a significant amount of variability and equipoise in the treatment of this condition. Medical therapy plays a significant role in optimizing coexistent cardiovascular risk factors and a limited role in improving limb outcomes in nonrevascularizable disease.
CONCLUSIONS AND RELEVANCE
Understanding critical limb ischemia and its treatment strategies is important for providing the best care for affected patients. Currently, ongoing randomized clinical trials in North America and the United Kingdom aim to provide data to support the best management of these patients.
Topics: Amputation, Surgical; Chronic Disease; Diabetes Complications; Diabetes Mellitus; Humans; Hyperbaric Oxygenation; Hyperlipidemias; Hypertension; Ischemia; Lower Extremity; Peripheral Arterial Disease; Platelet Aggregation Inhibitors; Smoking; Smoking Cessation; Upper Extremity
PubMed: 27551978
DOI: 10.1001/jamasurg.2016.2018 -
Current Problems in Cardiology Apr 2024The global epidemiological transition of atherosclerotic vascular diseases is witnessing a rapid redistribution of its burden, shifting from high-income to low- and... (Review)
Review
The global epidemiological transition of atherosclerotic vascular diseases is witnessing a rapid redistribution of its burden, shifting from high-income to low- and middle-income countries. With a wide clinical spectrum, spanning from intermittent claudication to more complex critical limb threatening ischemia, nonhealing ulcers, gangrene as well as acute limb ischemia, peripheral artery disease is often faced with the challenges of under-diagnosis and under-treatment despite its high prevalence. The management of peripheral arterial disease in patients with multiple comorbidities presents a formidable challenge and remains a pressing global health concern. In this review, we aim to provide an in-depth overview of the pathophysiology of peripheral artery disease and explore evidence-based management strategies encompassing pharmacological, lifestyle, interventional, and surgical approaches. By addressing these challenges, the review contributes to a better understanding of the evolving landscape of peripheral artery disease, offering insights into effective and holistic management strategies.
Topics: Humans; Peripheral Arterial Disease; Intermittent Claudication; Ischemia; Atherosclerosis; Comorbidity
PubMed: 38309544
DOI: 10.1016/j.cpcardiol.2024.102430 -
The American Journal of Emergency... Dec 2023Acute limb ischemia is a rare but serious condition that carries with it a high rate of morbidity and mortality. (Review)
Review
INTRODUCTION
Acute limb ischemia is a rare but serious condition that carries with it a high rate of morbidity and mortality.
OBJECTIVE
This review highlights the pearls and pitfalls of acute limb ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.
DISCUSSION
Acute limb ischemia is defined as a sudden decrease in limb perfusion resulting in cessation of blood flow and nutrient and oxygen delivery to the tissues. This leads to cellular injury and necrosis, ultimately resulting in limb loss and potentially systemic symptoms with significant morbidity and mortality. There are several etiologies including native arterial thrombosis, arterial thrombosis after an intervention, arterial embolus, and arterial injury. Patients with acute limb ischemia most commonly present with severe pain and sensory changes in the initial stages, with prolonged ischemia resulting in weakness, sensory loss, and color changes to the affected limb. The emergency clinician should consult the vascular specialist as soon as ischemia is suspected, as the diagnosis should be based on the history and examination. Computed tomography angiography is the first line imaging modality, as it provides valuable information concerning the vasculature and surrounding tissues. Doppler ultrasound of the distal pulses may also be obtained to evaluate for arterial and venous flow. Once identified, management includes intravenous unfractionated heparin and vascular specialist consultation for revascularization.
CONCLUSIONS
An understanding of acute limb ischemia can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
Topics: Humans; Heparin; Prevalence; Ischemia; Arterial Occlusive Diseases; Thrombosis; Peripheral Vascular Diseases; Acute Disease
PubMed: 37844359
DOI: 10.1016/j.ajem.2023.09.052 -
Journal of Vascular Surgery Jan 2016
Topics: Amputation, Surgical; Female; Hemodynamics; Humans; Ischemia; Lower Extremity; Male; Peripheral Arterial Disease
PubMed: 26412437
DOI: 10.1016/j.jvs.2015.07.102 -
International Journal of Cardiology Aug 2022Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides cardiovascular and respiratory support for patients in cardiogenic shock; yet, complications are a... (Meta-Analysis)
Meta-Analysis Review
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides cardiovascular and respiratory support for patients in cardiogenic shock; yet, complications are a frequent source of morbidity and mortality. Limb ischemia can be potentially mitigated by limp perfusion protection strategies (LPPS). We performed a systematic review and meta-analysis to evaluate the safety and efficacy of two LPPS in patients treated with peripheral VA-ECMO - prophylactic insertion of a distal perfusion catheter (DPC) and small bore (<17 Fr) arterial return cannula. Among 22 included studies, limb ischemia was reduced in patients receiving a small arterial cannula (OR 0.40, 95% CI 0.24-0.65; p < 0.001) and in patients receiving a prophylactic DPC (OR 0.31, 95% CI 0.21-0.47; p < 0.001). Mortality was not significantly reduced with either a small arterial cannula (OR 0.70, 95% CI 0.23-2.18; p = 0.54) or prophylactic DPC strategy (OR 0.89, 95% CI 0.67-1.17; p = 0.40). As such, prophylactic insertion of a DPC or smaller bore arterial return cannula appear to reduce the risk of lower limb ischemia in this analysis. Further data are needed to confirm these findings. Registration: Registered in PROSPERO Database (Registration CRD42020215677).
Topics: Catheterization, Peripheral; Extracorporeal Membrane Oxygenation; Femoral Artery; Humans; Ischemia; Peripheral Vascular Diseases; Retrospective Studies; Risk Factors; Shock, Cardiogenic
PubMed: 35523371
DOI: 10.1016/j.ijcard.2022.04.084 -
Techniques in Vascular and... Jun 2016Critical limb ischemia (CLI) has a high rate of major amputation and mortality due to advance systemic cardiovascular disease. The goals of treating patients with CLI... (Review)
Review
Critical limb ischemia (CLI) has a high rate of major amputation and mortality due to advance systemic cardiovascular disease. The goals of treating patients with CLI not only include the prevention of limb loss but also to relieve pain, improve quality of life, and prevent death. A multidisciplinary team approach to treating patients with CLI improves limb salvage rates by helping to tailor the best intervention for these patients. In addition, a multidisciplinary team can help address cardiovascular risk modification and wound management to help in decreasing mortality and increase amputation-free survival. This review article intends to summarize the current trends and data in the team approach to CLI care. In addition, we will review the large multidisciplinary study evaluating surgical and endovascular treatments for CLI.
Topics: Amputation, Surgical; Biomedical Research; Combined Modality Therapy; Endovascular Procedures; Hemodynamics; Humans; Ischemia; Limb Salvage; Lower Extremity; Patient Care Team; Patient Selection; Peripheral Arterial Disease; Quality of Life; Risk Factors; Treatment Outcome; Vascular Surgical Procedures
PubMed: 27423991
DOI: 10.1053/j.tvir.2016.04.002 -
Trends in Cardiovascular Medicine Aug 2016Peripheral arterial disease (PAD) is extremely prevalent, under-diagnosed and has a tremendous impact on the quality of life of patients with this condition. The... (Review)
Review
Peripheral arterial disease (PAD) is extremely prevalent, under-diagnosed and has a tremendous impact on the quality of life of patients with this condition. The foundation of PAD treatment is medical therapy in order to prevent its associated high rates of cardiovascular morbidity and mortality. This therapy should be instituted in all patients with PAD, regardless of symptomatic status. Though the majority of patients with PAD are asymptomatic, they remain at high risk for adverse events, underscoring the need to screen for this disease. This review will briefly touch on the medical therapy for PAD and highlight the necessity to make the diagnosis in all patients at risk. For those patients with symptoms from arterial insufficiency, the frontier of potential treatment options is ever expanding. In this review, the current options for patients with symptomatic lower extremity PAD are highlighted. Given the marked differences in treatment options and outcomes between the aorto-iliac, femoropopliteal and infrapopliteal vascular beds, each of these arenas are discussed separately. Contemporary techniques and data are discussed with respect to both vascular bed and presenting clinical scenario, i.e. claudication, critical limb ischemia and acute limb ischemia.
Topics: Critical Illness; Endovascular Procedures; Humans; Intermittent Claudication; Ischemia; Lower Extremity; Patient Selection; Peripheral Arterial Disease; Risk Factors; Treatment Outcome; Vascular Patency
PubMed: 27345154
DOI: 10.1016/j.tcm.2016.02.007 -
Age and Ageing Jun 2024Peripheral artery disease (PAD) is the lower limb manifestation of systemic atherosclerotic disease. PAD may initially present with symptoms of intermittent... (Review)
Review
Peripheral artery disease (PAD) is the lower limb manifestation of systemic atherosclerotic disease. PAD may initially present with symptoms of intermittent claudication, whilst chronic limb-threatening ischaemia (CLTI), the end stage of PAD, presents with rest pain and/or tissue loss. PAD is an age-related condition present in over 10% of those aged ≥65 in high-income countries. Guidelines regarding definition, diagnosis and staging of PAD and CLTI have been updated to reflect the changing patterns and presentations of disease given the increasing prevalence of diabetes. Recent research has changed guidelines on optimal medical therapy, with low-dose anticoagulant plus aspirin recommended in some patients. Recently published randomised trials highlight where bypass-first or endovascular-first approaches may be optimal in infra-inguinal disease. New techniques in endovascular surgery have increased minimally invasive options for ever more complex disease. Increasing recognition has been given to the complexity of patients with CLTI where a high prevalence of both frailty and cognitive impairment are present and a significant burden of multi-morbidity and polypharmacy. Despite advances in minimally invasive revascularisation techniques and reduction in amputation incidence, survival remains poor for many with CLTI. Shared decision-making is essential, and conservative management is often appropriate for older patients. There is emerging evidence of the benefit of specialist geriatric team input in the perioperative management of older patients undergoing surgery for CLTI. Recent UK guidelines now recommend screening for frailty, cognitive impairment and delirium in older vascular surgery patients as well as recommending all vascular surgery services have support and input from specialist geriatrics teams.
Topics: Humans; Peripheral Arterial Disease; Aged; Endovascular Procedures; Risk Factors; Chronic Limb-Threatening Ischemia; Vascular Surgical Procedures; Age Factors; Practice Guidelines as Topic
PubMed: 38877714
DOI: 10.1093/ageing/afae114 -
Presse Medicale (Paris, France : 1983) Jan 2018Medical management of peripheral arterial disease (PAD) patients is aimed at limb symptom relief and reducing systemic major adverse events risk. For the first purpose:... (Review)
Review
Medical management of peripheral arterial disease (PAD) patients is aimed at limb symptom relief and reducing systemic major adverse events risk. For the first purpose: exercise therapy is recommended in case of claudication; multidisciplinary evaluation for surgical options is mandatory in case of critical limb ischaemia. Reducing cardiac and stroke risk can be achieved through: statin prescription in most of the cases; antiplatelet agents in symptomatic PAD patients; cardio-vascular risk factors control.
Topics: Angiotensin-Converting Enzyme Inhibitors; Arteriosclerosis Obliterans; Disease Management; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Intermittent Claudication; Ischemia; Leg; Patient Education as Topic; Peripheral Arterial Disease; Platelet Aggregation Inhibitors; Risk Factors; Stroke; Thrombophilia; Vascular Grafting
PubMed: 29273182
DOI: 10.1016/j.lpm.2017.09.019 -
International Journal of Cardiology Apr 2023
Topics: Humans; Heart; Hemorrhage; Peripheral Arterial Disease; Ischemia
PubMed: 36706991
DOI: 10.1016/j.ijcard.2023.01.061