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South African Journal of Surgery.... Sep 2017This study investigated the pattern and distribution of peripheral arterial disease in diabetic patients with critical limb ischaemia (CLI) and to stratify the findings... (Clinical Trial)
Clinical Trial
BACKGROUND
This study investigated the pattern and distribution of peripheral arterial disease in diabetic patients with critical limb ischaemia (CLI) and to stratify the findings according to the patients' risk factor profile, gender and age group.
METHOD
We conducted a one-year prospective descriptive study (January 2014 to December 2014) at Groote Schuur Hospital, University of Cape Town. The research protocol and the informed consent were approved by the Institutional Review Board, and all subjects included in this study gave an informed consent. We included all diabetic patients over the age of 18 years with critical limb ischemia who had pre and post-intervention vascular imaging. The calculated minimum sample size was 63 limbs. We hypothesize that the proportions of arterial segment patency categories and the arterial foot arch status varies according to gender, age group and risk factor combinations in diabetic patients. The Null hypothesis (N0) assumes that the proportions of arterial segment patency categories and arch status are the same in diabetic patients irrespective of gender, age group and risk factor combination. The equality of distribution was analysed using the One Sample Chi-square test. Three risk factor combination groups were analysed: Group 1 (diabetes mellitus, hypertension, dyslipidemia), Group 2 (diabetes mellitus, hypertension, dyslipidemia, ex-smoker) and Group 3 (diabetes mellitus, hypertension, dyslipidemia, smoker).
RESULTS
Seventy-one patients were analysed (38 females and 33 males). We recorded the patency grades (ranging from normal to occlusion) of arteries in all 3 lower extremity arterial segments (aortoiliac; femoropopliteal and tibioperoneal segments). Altogether the patency grades of 820 lower extremity arteries were recorded. Diabetics, collectively, were found to have more severe occlusive disease in the tibioperoneal segment (P < .001). Group 3 patients however, had more severe occlusive disease in the femoropopliteal segment compared to the other subgroups (P < .001). Group 1 and Group 2 patients had more severe occlusive disease in the tibioperoneal segment (P < .001). Females were more likely to have complete foot arches (22/37; P = .004) while males tended to have more incomplete foot arches (17/32; P = .048).
CONCLUSION
Diabetic patients collectively have severe tibioperoneal occlusive disease. However, Group 3 patients tend to have disproportionately more occlusive disease in the femoropopliteal segment (P < .001). Diabetic female patients with CLI are more likely to have a complete arterial foot arch than males (P = .004).
Topics: Adult; Aged; Aged, 80 and over; Diabetic Angiopathies; Female; Humans; Ischemia; Lower Extremity; Male; Middle Aged; Peripheral Arterial Disease; Prospective Studies; Risk Factors; Severity of Illness Index; Sex Factors
PubMed: 28876565
DOI: No ID Found -
Practical Neurology Feb 2023A 57-year-old man was diagnosed with acute myocardial infarction and Stanford type A aortic dissection that had spread to the common iliac arteries. He underwent a...
A 57-year-old man was diagnosed with acute myocardial infarction and Stanford type A aortic dissection that had spread to the common iliac arteries. He underwent a Bentall procedure for vascular repair. Immediately after surgery, he developed numbness and severe weakness in his left leg. On examination, he had hypotonia, absent deep tendon reflexes, weakness in the left leg (Medical Research Council (MRC) scale for muscle strength - 0/5 distal, 3/5 proximal) and reduced sensation in the left leg. Electromyography confirmed subacute involvement of the left lumbar and lumbosacral plexus. MR scan of the lumbar plexus showed diffuse muscle oedema involving the left gluteus maximus. We diagnosed ischaemic lumbosacral plexopathy secondary to extensive aorta dissection and internal iliac artery occlusion. We discuss the clinical features of ischaemic plexopathy and the diagnostic approach and review the vascular anatomy of the lumbosacral plexus.
Topics: Male; Humans; Middle Aged; Ischemia; Iliac Artery; Muscle, Skeletal; Electromyography; Aortic Dissection
PubMed: 35995555
DOI: 10.1136/pn-2022-003462 -
Cardiovascular Journal of AfricaThromboangitis obliteransis (TAO) is a nonatherosclerotic, inflammatory, occlusive arteritis that affects small and medium-sized arteries, veins and nerves. A large...
OBJECTIVES
Thromboangitis obliteransis (TAO) is a nonatherosclerotic, inflammatory, occlusive arteritis that affects small and medium-sized arteries, veins and nerves. A large proportion of patients with TAO suffer from claudication, and the ultimate condition is gangrene and limb loss if there is no treatment or the cessation of smoking. Endovascular revascularisations are performed frequently and provide acceptable results in patients who are not suitable for surgery. In this study, we aimed to show our clinical experience in patients with TAO who were treated with endovascular revascularisation.
METHODS
Between January 2014 and March 2020, 18 patients with lower-extremity critical limb ischaemia (CLI) underwent endovascular treatment (ET). Technical details and clinical success at follow up were documented.
RESULTS
This study included 18 patients with lower-extremity TAO who presented with CLI and were treated with ET. The mean age of the patients was 38.8 ± 7.3 years. Fifty per cent of patients had pain at rest, 33.7% had minor tissue loss and non-healing ulcers, and 16.7% had major tissue loss on admission. The majority of lesions were located in the peroneal and tibial arteries ( = 13, 72.27percnt;). Two (11.1%) patients had distal superficial femoral artery occlusion concomitant with popliteal artery (PA) lesions, and three (16.7%) had PA occlusion concomitant with peroneal and tibial artery lesions. Re-establishment of antegrade flow in at least one vessel was achieved in 15 (83.3%) patients. Balloon angioplasty was performed in all patients. Plain old balloon angioplasty (POBA) was used in nine (60%) patients and drug-eluting balloon (DEB) angioplasty in six (40%). The mean duration of follow up in 15 patient who had undergone successful ET was 21.5 ± 8.1 months. The primary CLI-free rate at 12 and 24 months was 80% (66.7% in all patients). Secondary CLI-free rates at six, 12 and 24 months were 100, 93.3 and 53.3%, respectively. Patients who were active smokers during their follow up had a higher frequency of out-patient clinic consultations ( = 0.03).
CONCLUSION
Controversy has continued on the role of ET in the treatment of TAO. This study shows that ET of TAO had promising primary and secondary patency rates with high technical success and limb-salvage rates.
Topics: Humans; Adult; Middle Aged; Thromboangiitis Obliterans; Chronic Limb-Threatening Ischemia; Treatment Outcome; Popliteal Artery; Angioplasty, Balloon; Limb Salvage; Peripheral Arterial Disease; Ischemia; Vascular Patency
PubMed: 35789369
DOI: 10.5830/CVJA-2022-018 -
VASA. Zeitschrift Fur Gefasskrankheiten Jan 2018Patients with critical limb ischaemia have a poor life expectancy. Aggressive revascularization is accepted in order to preserve their independence in the final phase of... (Review)
Review
Patients with critical limb ischaemia have a poor life expectancy. Aggressive revascularization is accepted in order to preserve their independence in the final phase of their lives. Bypass surgery and more recently endovascular interventions with angioplasty and stenting have become the treatment of choice to prevent amputation and to resolve pain. However, as many as 20 % of patients with critical limb ischaemia are unsuitable candidates for a vascular intervention because of extensive occlusions of outflow in the crural and pedal vessels. Such "no-option critical limb ischaemia" may be treated with venous arterialization. In the present review, we discuss the history of the venous arterialization procedure, the mechanisms, the different techniques, and complications of venous arterialization.
Topics: Humans; Ischemia; Limb Salvage; Lower Extremity; Peripheral Arterial Disease; Regional Blood Flow; Vascular Patency
PubMed: 29065790
DOI: 10.1024/0301-1526/a000669 -
Biological Chemistry Dec 2016Genetic and pharmacological studies, clinical and experimental, focused on kallikrein-K1, kinin receptors and ACE/kininase II suggest that kinin release in the settings... (Review)
Review
Genetic and pharmacological studies, clinical and experimental, focused on kallikrein-K1, kinin receptors and ACE/kininase II suggest that kinin release in the settings of ischemia or diabetes reduces organ damage, especially in the heart and kidney. Kinin bioavailability may be a limiting factor for efficacy of current kinin-potentiating drugs, like ACE inhibitors. Primary activation of kinin receptors by prototypic pharmacological agonists, peptidase-resistant, selective B1 or B2, displays therapeutic efficacy in experimental cardiac and peripheral ischemic and diabetic diseases. B1R agonism was especially efficient in diabetic animals and had no unwanted effects. Clinical development of kinin receptor agonists may be warranted.
Topics: Animals; Diabetes Mellitus; Humans; Ischemia; Kallikrein-Kinin System
PubMed: 27622831
DOI: 10.1515/hsz-2016-0228 -
The Cochrane Database of Systematic... Dec 2014Peripheral arterial disease is a major health problem, and in about 1% to 2% of patients the disease progresses to critical limb ischaemia (CLI). In a substantial number... (Review)
Review
BACKGROUND
Peripheral arterial disease is a major health problem, and in about 1% to 2% of patients the disease progresses to critical limb ischaemia (CLI). In a substantial number of patients with CLI, no effective treatment option other than amputation is available and around a quarter of these patients will require a major amputation during the following year. This is an update of the review first published in 2011.
OBJECTIVES
To determine the effectiveness and safety of local intramuscular transplantation of autologous adult bone marrow mononuclear cells (BMMNCs) as a treatment for critical limb ischaemia (CLI).
SEARCH METHODS
For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched February 2014) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1).
SELECTION CRITERIA
We included all randomised controlled trials of CLI in which participants were randomly allocated to intramuscular administration of autologous adult BMMNCs or control (either no intervention or conventional conservative therapy). We excluded studies on patients with intermittent claudication.
DATA COLLECTION AND ANALYSIS
Two authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data. Disagreements were resolved by consensus or by the third author.
MAIN RESULTS
Only two small studies, with a combined total of 57 participants, met our inclusion criteria and were finally included. They were classified as having a moderate risk of bias with unclear issues regarding their methods, and according to the GRADE approach, the overall quality of the evidence would be considered as moderate. In one study the effects of intramuscular injections of BMMNCs in the ischaemic lower limbs of patients with CLI were compared with control (standard conservative treatment). No deaths were reported and no significant difference was observed between the two groups for either pain (P = 0.37) or the ankle brachial index (ABI) parameter. However, the treatment group showed a significantly smaller proportion of participants undergoing amputation compared with the control group (P = 0.026).In the other study, following subcutaneous injections of granulocyte colony-stimulating factor (G-CSF) for five days, peripheral blood derived mononuclear cells were collected and then transplanted by intramuscular injections into ischaemic lower limbs. The effects were compared with daily intravenous prostaglandin E1 injections (control group). No deaths were reported. Pain reduction was greater in the treatment group than in the control group (P < 0.001) as was increase in ABI (mean increase 0.13 versus 0.02, P < 0.01). The treatment group experienced a statistically significant increase in pain-free walking distance (PFWD) compared with the control group (mean increase 306.4 m versus 78.6 m, P = 0.007). A smaller proportion of participants underwent amputation in the treatment group compared with the control group (0% versus 36%, P = 0.007).
AUTHORS' CONCLUSIONS
The data from the published trials suggest that there is insufficient evidence to support this treatment. These results were based on only two trials which had a very small number of participants. Therefore evidence from larger randomised controlled trials is needed in order to provide adequate statistical power to assess the role of intramuscular mononuclear cell implantation in patients with CLI.
Topics: Adult; Alprostadil; Amputation, Surgical; Ankle Brachial Index; Bone Marrow Transplantation; Granulocyte Colony-Stimulating Factor; Humans; Injections, Intramuscular; Ischemia; Leg; Leukocytes, Mononuclear; Pain Measurement; Peripheral Vascular Diseases; Randomized Controlled Trials as Topic; Transplantation, Autologous; Vasodilator Agents
PubMed: 25525690
DOI: 10.1002/14651858.CD008347.pub3 -
Journal of Cardiothoracic and Vascular... Nov 2020Acute limb ischemia caused by peripheral venoarterial extracorporeal membrane oxygenation (ECMO) cannulation is associated with increased mortality. Early detection of... (Review)
Review
Acute limb ischemia caused by peripheral venoarterial extracorporeal membrane oxygenation (ECMO) cannulation is associated with increased mortality. Early detection of limb hypoperfusion may lead to timely intervention and prevent irreversible muscle damage. Methods to determine the adequacy of tissue oxygenation in cannulated extremities include bedside physical examination, trending serum biochemical markers, and somatic near-infrared spectroscopy. To prevent ECMO-related limb ischemia events, interventions include the addition of distal antegrade perfusion catheters to the arterial ECMO canula, minimizing arterial cannula diameter, placing arterial and venous cannulae on opposite extremities, and adding a side-arm graft to the cannulated artery. If the limb develops early signs of ischemia, preventative measures such as distal perfusion catheter insertion or changing the location of the arterial cannula should be performed. Acute compartment syndrome requires emergency fasciotomy or amputation if the limb is unsalvageable. Opportunities for future research include improving monitoring technology and standardizing the use of the distal perfusion catheter.
Topics: Adult; Catheterization, Peripheral; Extracorporeal Membrane Oxygenation; Femoral Artery; Humans; Ischemia; Retrospective Studies
PubMed: 32217044
DOI: 10.1053/j.jvca.2020.02.020 -
Journal of Vascular Surgery Jan 2016Critical limb ischemia is associated with a significant morbidity and mortality. We systematically reviewed the evidence to compare bypass surgery with endovascular... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Critical limb ischemia is associated with a significant morbidity and mortality. We systematically reviewed the evidence to compare bypass surgery with endovascular revascularization in patients with critical limb ischemia.
METHODS
We systematically searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, CINAHL, and Scopus through October 2014 for comparative studies (randomized and nonrandomized). Predefined outcomes of interest were mortality, major amputation, patency, and wound healing. We pooled odds ratios (ORs) of the outcomes of interest using the random-effects model.
RESULTS
Nine studies that enrolled 3071 subjects were included. There was no significant difference in mortality (OR, 0.72; 95% confidence interval [CI], 0.44-1.16) or amputation (OR, 1.2; 95% CI, 0.87-1.65). Bypass surgery was associated with higher primary patency (OR, 2.50; 95% CI, 1.25-4.99) and assisted primary patency (OR, 3.39; 95% CI, 1.53-7.51). The quality of evidence was low for mortality and amputation outcomes and moderate for patency outcomes.
CONCLUSIONS
Low quality of evidence due to imprecision and heterogeneity suggests that bypass surgery and endovascular approaches may have similar effect on mortality and major amputations. However, better primary and primary assisted patency can be expected with surgery.
Topics: Aged; Amputation, Surgical; Blood Vessel Prosthesis Implantation; Critical Illness; Endovascular Procedures; Female; Humans; Ischemia; Lower Extremity; Male; Middle Aged; Odds Ratio; Peripheral Arterial Disease; Risk Factors; Time Factors; Treatment Outcome; Vascular Patency; Wound Healing
PubMed: 26372187
DOI: 10.1016/j.jvs.2015.07.068 -
Journal of Vascular Surgery Jun 2022Vascular complications remain a prevalent and devastating complication of extracorporeal membrane oxygenation (ECMO). Risks for vascular complications have risen as the...
BACKGROUND
Vascular complications remain a prevalent and devastating complication of extracorporeal membrane oxygenation (ECMO). Risks for vascular complications have risen as the volume and medical complexity of ECMO cases has rapidly increased in recent years. This study assesses occurrence and clinical impact of vascular complications across all ECMO modes and cannulation methods in a high-volume academic center.
METHODS
A retrospective single-institution review was performed of all ECMO cannulations for central or peripheral venovenous (VV) or venoarterial (VA) ECMO in 2019-2020. Patients who expired during cannulation were excluded. Primary outcomes of vascular consultation rates at or after ECMO placement, limb loss, and mortality were assessed during index hospitalization.
RESULTS
A total of 229 patients were identified during the 2-year study period. VA ECMO was used in the majority of patients (n = 137, 60%), with 83% (N = 114) undergoing peripheral cannulation. Vascular surgery was consulted in 54 (23.6%) patients. Complication rates ranged from 33.9% in peripheral VA cannulation to 7% in jugular VV cannulation. Overall, 65% of vascular consults required operative intervention; interventions were highest in peripheral VA ECMO (n = 30 of 114, 26.3%). Across all ECMO types, acute limb ischemia (ALI) was the most common complication (n = 38, 16.5%), with rates ranging from 26.1% in central VA ECMO to 4.8% in jugular VV ECMO. Distal antegrade perfusion catheters (DPCs) were employed in n = 68 of 114 (59.6%) of all peripheral VA ECMO cases. Prophylactic DPCs were found to be incorrectly placed in 10.2% (n = 7 of 68) of cases, which obscured the ability to fully evaluate the effect of prophylactic DPCs on reducing rates of ALI. Major amputation (Below Knee Amputation/Above Knee Amputation) occurred in six peripheral VA patients (5.3%), two central VA patients (8.65), and two femoral-femoral VV patients (4%). Patients with ALI experienced significantly lower rates of in-hospital survival in Kaplan-Meier analysis (32.5% vs 54%, log-rank = 0.023).
CONCLUSIONS
This study highlights the prevalence of vascular complications, and their associated mortality impact, across all modes of ECMO and additionally identifies several areas for institutional performance improvement. ALI was the most common complication across all cohorts and was associated with decreased in-hospital survival. The impact of DPC on ALI was difficult to elucidate due to nonstandardized placement patterns and selective use. In the care of these medically complex patients on multidisciplinary teams, review of outcomes and group discussions targeting areas for improvement are critical to success; in this study, findings resulted in the development of a lower extremity perfusion management protocol.
Topics: Cardiovascular Diseases; Catheterization, Peripheral; Extracorporeal Membrane Oxygenation; Femoral Artery; Humans; Ischemia; Retrospective Studies; Risk Factors
PubMed: 35090988
DOI: 10.1016/j.jvs.2022.01.078 -
Journal de Medecine Vasculaire Feb 2022
Topics: Chronic Limb-Threatening Ischemia; Humans; Ischemia; Peripheral Arterial Disease
PubMed: 35393085
DOI: 10.1016/j.jdmv.2022.01.137