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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 -
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 -
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 -
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 -
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 -
Annals of Vascular Surgery Aug 2022For many surgeons the outbreak of SARS-CoV-2 meant a downscaling of surgical interventions. The aim of this study was to investigate the impact of the measures taken on...
BACKGROUND
For many surgeons the outbreak of SARS-CoV-2 meant a downscaling of surgical interventions. The aim of this study was to investigate the impact of the measures taken on the care for patients with peripheral arterial disease (PAOD) and acute limb ischemia (ALI).
METHODS
A retrospective analysis of the vascular practices of 2 major teaching hospitals in the Netherlands was performed. All interventions and outpatient visits for PAOD or ALI in 2020 were included. Patients treated in 2018 and 2019 were to serve as a control group. Data were analysed using descriptive statistics.
RESULTS
In 2020, a total of 1513 procedures were performed for PAOD or ALI. This did not differ significantly from previous years. Overall, Fontaine 2 and 4 were the most frequent indications for intervention. A significant increase in the number of major amputations was observed in 2020 compared to 2018 (P< 0.01). This was mainly due to patients suffering from PAOD Fontaine 4. Inversely, a reduction in the number of femoro-popliteal bypasses was observed between 2020 and 2018. The number of outpatient visit due to Fontaine 2 was significantly lower in 2020 compared to 2018.
CONCLUSIONS
The vascular practices of our hospitals were minimally influenced by the measures taken due to the outbreak of SARS-CoV-2. There was an increase in the number of amputation but an enormous surge in patients presenting with critical limb ischemia was not observed.
Topics: Amputation, Surgical; Arterial Occlusive Diseases; COVID-19; Humans; Ischemia; Limb Salvage; Pandemics; Peripheral Arterial Disease; Retrospective Studies; Risk Factors; SARS-CoV-2; Treatment Outcome
PubMed: 35108551
DOI: 10.1016/j.avsg.2022.01.012 -
International Journal of Cardiology Apr 2023
Topics: Humans; Heart; Hemorrhage; Peripheral Arterial Disease; Ischemia
PubMed: 36706991
DOI: 10.1016/j.ijcard.2023.01.061 -
Circulation Aug 2019Acute limb ischemia (ALI) is an important clinical event and an emerging cardiovascular clinical trial outcome. Risk factors for and outcomes after ALI have not been... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Acute limb ischemia (ALI) is an important clinical event and an emerging cardiovascular clinical trial outcome. Risk factors for and outcomes after ALI have not been fully evaluated.
METHODS
EUCLID (Examining Use of Ticagrelor in Peripheral Artery Disease) randomized patients with peripheral artery disease to ticagrelor versus clopidogrel. Enrollment criteria included an ankle-brachial index ≤0.80 or previous lower extremity revascularization. Patients were grouped according to the primary outcome, postrandomization ALI hospitalization. Baseline factors associated with ALI were identified using Cox proportional hazards modeling. Models with ALI hospitalization as a time-dependent covariate were developed for secondary outcomes of major adverse cardiovascular events (myocardial infarction, cardiovascular death, ischemic stroke), all-cause mortality, and major amputation.
RESULTS
Among 13 885 patients, 1.7% (n=232) had 293 ALI hospitalizations (0.8 per 100 patient-years). Patients with versus without ALI were younger and more often had previous peripheral revascularization and lower baseline ankle-brachial index. Treatment during ALI hospitalization included endovascular revascularization (39.2%, n=115), surgical bypass (24.6%, n=72), and major amputation (13.0%, n=38). After multivariable adjustment, any previous peripheral revascularization (Hazard Ratio [HR] 4.7, 95% CI 3.3-6.8, P<0.01), baseline atrial fibrillation (HR 1.8, 95% CI 1.1-3.2, P=0.03), and baseline ankle-brachial index ≤0.60 (HR 1.3 per 0.10 decrease, 95% CI 1.1-1.5, P<0.01) were associated with higher ALI risk. Older age (HR 0.8 per 10-year increase, 95% CI 0.7-1.0, P=0.02) and baseline statin use (HR 0.7, 95% CI 0.5-0.9, P<0.01) were associated with lower risk for ALI. There was no relationship between randomized treatment to ticagrelor or clopidogrel and ALI. Among patients with previous revascularization, surgical versus endovascular procedures performed more than 6 months prior were associated with ALI (adjusted HR 2.63, 95% CI 1.75-3.96). In the overall population, ALI hospitalization was associated with subsequent MACE (adjusted HR 1.4, 95% CI 1.0-2.1, P=0.04), all-cause mortality (adjusted HR 3.3, 95% CI 2.4-4.6, P<0.01), and major amputation (adjusted HR 34.2, 95% CI 9.7-20.8, P<0.01).
CONCLUSIONS
Previous peripheral revascularization, baseline atrial fibrillation, and lower ankle-brachial index identify peripheral artery disease patients at heightened risk for ALI, an event associated with subsequent cardiovascular and limb-related morbidity and mortality.
CLINICAL TRIAL REGISTRATION
URL: https://www.clinicaltrials.gov. Unique identifier: NCT01732822.
Topics: Acute Disease; Aged; Double-Blind Method; Female; Hospitalization; Humans; Ischemia; Lower Extremity; Male; Middle Aged; Peripheral Arterial Disease; Platelet Aggregation Inhibitors; Ticagrelor
PubMed: 31238713
DOI: 10.1161/CIRCULATIONAHA.119.039773 -
European Journal of Preventive... May 2022Peripheral artery disease (PAD) patients suffer a high risk of major cardiovascular (CV) events, with athero-thrombo-embolism as the underlying pathophysiologic...
AIMS
Peripheral artery disease (PAD) patients suffer a high risk of major cardiovascular (CV) events, with athero-thrombo-embolism as the underlying pathophysiologic mechanism. Recently, two large randomized clinical trials evaluated the efficacy and safety of low-dose rivaroxaban twice daily plus aspirin in stable PAD outpatients and those immediately after peripheral revascularization. We sought to determine if the effects of low-dose rivaroxaban and aspirin compared to aspirin alone are consistent across this broad spectrum of PAD patients.
METHODS AND RESULTS
We conducted a random-effects meta-analysis of the COMPASS and VOYAGER randomized trials among 11 560 PAD patients (4996 from COMPASS and 6564 from VOYAGER) in the primary analysis and 9332 (2768 from COMPASS and 6564 from VOYAGER) with lower extremity (LE)-PAD in the secondary analysis. The hazard ratio (HR) for the composite of CV death, myocardial infarction, ischaemic stroke, acute limb ischaemia, or major vascular amputation was 0.79 (95% confidence interval, CI: 0.65-0.95) comparing low-dose rivaroxaban plus aspirin to aspirin alone. While the risk of major bleeding was increased with low-dose rivaroxaban plus aspirin compared to aspirin alone [HR: 1.51 (95% CI: 1.22-1.87)], there was no significant increase in severe bleeding [HR: 1.18 (95% CI: 0.79-1.76)]. Similar effects were observed in the subset with symptomatic LE-PAD.
CONCLUSIONS
Among PAD patients, low-dose rivaroxaban plus aspirin is superior to aspirin alone in reducing CV and limb outcomes including acute limb ischaemia and major vascular amputation. This reduction is offset by a relative increase in major bleeding, but not by an excess of fatal or critical organ bleeding. The consistency of findings of these trials supports the use of combination low-dose rivaroxaban plus aspirin in PAD patients across a broad spectrum of disease.
Topics: Aspirin; Brain Ischemia; Drug Therapy, Combination; Factor Xa Inhibitors; Fibrinolytic Agents; Hemorrhage; Humans; Ischemia; Peripheral Arterial Disease; Platelet Aggregation Inhibitors; Rivaroxaban; Stroke
PubMed: 34463737
DOI: 10.1093/eurjpc/zwab128