-
Seminars in Vascular Surgery Jun 2022The incidence of peripheral artery disease continues to rise worldwide, with a concomitant rise in the subset of patients who manifest with chronic limb-threatening... (Review)
Review
The incidence of peripheral artery disease continues to rise worldwide, with a concomitant rise in the subset of patients who manifest with chronic limb-threatening ischemia (CLTI). A mainstay of CLTI treatment is revascularization through open surgical bypass, endovascular therapy, or hybrid approaches combining the two modalities. However, a significant proportion of these patients are considered to have nonreconstructable, or no-option, CLTI. This is related to either significant pedal arterial occlusive disease or lack of a bypass conduit. Deep vein arterialization has been used as a potential treatment option for this cohort of patients. We explore the various described methodologies of deep vein arterialization, including open, hybrid, and totally percutaneous. These studies suggest that deep vein arterialization is a promising treatment paradigm for patients with no-option CLTI, with encouraging results in terms of technical feasibility, wound healing, and ultimately limb salvage. However, further study of appropriate patient selection, standardization of techniques, and long-term follow-up are needed.
Topics: Amputation, Surgical; Chronic Disease; Chronic Limb-Threatening Ischemia; Endovascular Procedures; Humans; Ischemia; Limb Salvage; Peripheral Arterial Disease; Risk Factors; Time Factors; Treatment Outcome
PubMed: 35672111
DOI: 10.1053/j.semvascsurg.2022.05.002 -
Current Cardiology Reports Mar 2022Team-based care has been proposed as a tool to improve health care delivery, especially for the treatment of complex medical conditions. Chronic limb-threatening... (Review)
Review
PURPOSE OF REVIEW
Team-based care has been proposed as a tool to improve health care delivery, especially for the treatment of complex medical conditions. Chronic limb-threatening ischemia (CLTI) is a complex disease associated with significant morbidity and mortality which often involves the care of multiple specialty providers. Coordination of efforts across the multiple physician specialists, nurses, wound care specialists, and administrators is essential to providing high-quality and efficient care. The aim of this review is to discuss the multiple facets of care of the CLTI patient and to describe components important for a team-based care approach.
RECENT FINDINGS
Observational studies have reported improved outcomes when using a team-based care approach in the care of the patients with CLTI, including reduction in mean wound healing times, decreasing rate of amputations, and readmissions. Team-based care can streamline care of CLTI patients by raising awareness, facilitating early recognition, and providing prompt vascular assessment, revascularization, and surveillance. This approach has the potential to improve patient outcomes and reduce downstream health care costs.
Topics: Amputation, Surgical; Chronic Limb-Threatening Ischemia; Humans; Ischemia; Treatment Outcome; Vascular Surgical Procedures
PubMed: 35129740
DOI: 10.1007/s11886-022-01643-2 -
Journal of Vascular Surgery May 2022Chronic limb-threatening ischemia (CLTI) causes significant morbidity with profound negative effects on health-related quality of life. As the prevalence of peripheral... (Review)
Review
Chronic limb-threatening ischemia (CLTI) causes significant morbidity with profound negative effects on health-related quality of life. As the prevalence of peripheral artery disease and diabetes continue to rise in our aging population, the public health impact of CLTI has escalated. Patient-reported outcome measures (PROMs) have become common and important measures for clinical evaluation in both clinical care and research. PROMs are important for the measurement of clinical effectiveness and cost effectiveness and for shared decision-making on treatment options. However, the PROMs used to describe the experience of patients with CLTI are heterogeneous, incomplete, and lack specific applicability to the underlying disease processes and diverse populations. For example, certain PROMs exist for patients with extremity wounds, and other PROMs exist for patients with pain, and still others exist for patients with vascular disease. Despite this multiplicity of tools, no single PROM encompasses all of the components necessary to describe the experiences of patients with CLTI. This significant unmet need is evident from both published reports and contemporary large-scale clinical trials in the field. In this systematic review, we review the current use of PROMs for patients with CLTI in clinical practice and in research trials and highlight the gaps that need to be addressed to develop a unifying PROM instrument for CLTI.
Topics: Aged; Amputation, Surgical; Chronic Disease; Chronic Limb-Threatening Ischemia; Humans; Ischemia; Limb Salvage; Patient Reported Outcome Measures; Peripheral Arterial Disease; Quality of Life; Retrospective Studies; Risk Factors; Treatment Outcome
PubMed: 35085747
DOI: 10.1016/j.jvs.2021.11.057 -
European Journal of Cardio-thoracic... Aug 2023The aim of this study was to evaluate the incidence and outcomes of ischaemic organ complications after thoracic endovascular aortic repair (TEVAR). (Observational Study)
Observational Study
OBJECTIVES
The aim of this study was to evaluate the incidence and outcomes of ischaemic organ complications after thoracic endovascular aortic repair (TEVAR).
METHODS
This is a multicentre, retrospective, observational cohort study. We analysed data from patients treated with TEVAR between 22 June 2001 and 10 December 2022. Primary outcomes were postoperative overall organ ischaemic complications and early (≤30 days) survival. Secondary outcomes were long-term survival and freedom from aorta-related mortality.
RESULTS
A total of 255 patients were included in this study. We performed 233 (91.4%) isolated TEVARs, 14 (5.5%) fenestrated or branched TEVARs and 8 (3.1%) TEVARs in combination with normal infrarenal stent graft. Overall, 31 organ ischaemic complications were detected in 29 (11.4%) cases, out of which 8 (3.1%) complications were cerebrovascular, 8 (3.1%) spinal cord, 6 (2.3%) visceral, 4 (1.6%) renal, 2 (0.8%) peripheral and 3 (1.2%) myocardial. Binary logistic regression analysis identified grade III-IV aortic arch atheroma [odds ratio (OR): 6.6, P = 0.001; 95% confidence interval: 2.9-14.9] and shaggy aorta (OR: 12.1, P = 0.003; 95% confidence interval: 2.3-64.1) to be associated with the development of organ ischaemic complications. In patients with organ ischaemia, we observed higher early (≤30 days) mortality (20.7% vs 6.2%; OR: 3.6, P = 0.016), prolonged hospitalization (P = 0.001) and inferior estimated survival (log-rank, P = 0.001).
CONCLUSIONS
Aortic arch atherosclerotic overload as well as the presence of shaggy aorta are predictors of organ ischaemic complications following TEVAR. They are neither uncommon nor negligible and are associated with perioperative mortality, prolonged hospitalization and a negative impact on long-term survival.
Topics: Humans; Endovascular Aneurysm Repair; Blood Vessel Prosthesis Implantation; Retrospective Studies; Endovascular Procedures; Aorta, Thoracic; Postoperative Complications; Ischemia; Aortic Aneurysm, Thoracic; Treatment Outcome; Risk Factors
PubMed: 37335859
DOI: 10.1093/ejcts/ezad238 -
Arteriosclerosis, Thrombosis, and... Nov 2020This brief review summarizes current evidence regarding lower extremity peripheral artery disease (PAD) and lower extremity skeletal muscle pathology. Lower extremity... (Review)
Review
This brief review summarizes current evidence regarding lower extremity peripheral artery disease (PAD) and lower extremity skeletal muscle pathology. Lower extremity ischemia is associated with reduced calf skeletal muscle area and increased calf muscle fat infiltration and fibrosis on computed tomography or magnetic resonance imaging. Even within the same individual, the leg with more severe ischemia has more adverse calf muscle characteristics than the leg with less severe ischemia. More adverse computed tomography-measured calf muscle characteristics, such as reduced calf muscle density, are associated with higher rates of mobility loss in people with PAD. Calf muscle in people with PAD may also have reduced mitochondrial activity compared with those without PAD, although evidence is inconsistent. Muscle biopsy document increased oxidative stress in PAD. Reduced calf muscle perfusion, impaired mitochondrial activity, and smaller myofibers are associated with greater walking impairment in PAD. Preliminary evidence suggests that calf muscle pathology in PAD may be reversible. In a small uncontrolled trial, revascularization improved both the ankle-brachial index and mitochondrial activity, measured by calf muscle phosphocreatine recovery time. A pilot clinical trial showed that cocoa flavanols increased measures of myofiber health, mitochondrial activity, and capillary density while simultaneously improving 6-minute walk distance in PAD. Calf muscle pathological changes are associated with impaired walking performance in people with PAD, and interventions that both increase calf perfusion and improve calf muscle health are promising therapies to improve walking performance in PAD.
Topics: Animals; Energy Metabolism; Exercise Tolerance; Humans; Ischemia; Leg; Mitochondria, Muscle; Muscle, Skeletal; Oxidative Stress; Peripheral Arterial Disease; Prognosis; Regional Blood Flow; Walking
PubMed: 32938218
DOI: 10.1161/ATVBAHA.120.313831 -
Diabetes/metabolism Research and Reviews Mar 2024Diabetes is a key risk factor for ischaemic foot disease, which causes pain, tissue loss, hospital admission, and major amputation. Currently, treatment focuses on... (Review)
Review
Diabetes is a key risk factor for ischaemic foot disease, which causes pain, tissue loss, hospital admission, and major amputation. Currently, treatment focuses on revascularisation, but many patients are unsuitable for surgery and revascularisation is frequently unsuccessful. The authors describe recent research in animal models and clinical trials investigating novel medical targets for ischaemia, including theories about impaired wound healing, animal models for limb ischaemia and recent randomised controlled trials testing novel medical therapies. Novel targets identified in animal models included stimulating mobilisation of CD34+ progenitor cells through upregulating oncostatin M or microRNA-181, downregulating tumour necrosis factor superfamily member 14, or activating the Wingless pathway. Within the ischaemic limb vasculature, upregulation of apolipoprotein L domain containing 1, microRNA-130b or long noncoding RNA that enhances endothelial nitric oxide synthase expression promoted limb blood supply recovery, angiogenesis, and arteriogenesis. Similarly, administration of soluble guanylate cyclase stimulators riociguat or praliciguat or 3-ketoacyl-CoA thiolase inhibitor trimetazidine promoted blood flow recovery. Translating pre-clinical findings to patients has been challenging, mainly due to limitations in clinically translatable animal models of human disease. Promising results have been reported for administering plasmids encoding hepatocyte growth factor or intra-arterial injection of bone marrow derived cells in small clinical trials. It remains to be seen whether these high resource therapies can be developed to be widely applicable. In conclusion, an ever-expanding list of potential targets for medical revascularisation is being identified. It is hoped that through ongoing research and further larger clinical trials, these will translate into new broadly applicable therapies to improve outcomes.
Topics: Animals; Humans; Ischemia; Risk Factors; Foot Diseases; MicroRNAs
PubMed: 37563926
DOI: 10.1002/dmrr.3703 -
The Journal of Physiology Jul 2022Remote ischaemic preconditioning (RIPC), induced by intermittent periods of limb ischaemia and reperfusion, confers cardiac and vascular protection from subsequent... (Review)
Review
Remote ischaemic preconditioning (RIPC), induced by intermittent periods of limb ischaemia and reperfusion, confers cardiac and vascular protection from subsequent ischaemia-reperfusion (IR) injury. Early animal studies reliably demonstrate that RIPC attenuated infarct size and preserved cardiac tissue. However, translating these adaptations to clinical practice in humans has been challenging. Large clinical studies have found inconsistent results with respect to RIPC eliciting IR injury protection or improving clinical outcomes. Follow-up studies have implicated several factors that potentially affect the efficacy of RIPC in humans such as age, fitness, frequency, disease state and interactions with medications. Thus, realizing the clinical potential for RIPC may require a human experimental model where confounding factors are more effectively controlled and underlying mechanisms can be further elucidated. In this review, we highlight recent experimental findings in the peripheral circulation that have added valuable insight on the mechanisms and clinical benefit of RIPC in humans. Central to this discussion is the critical role of timing (i.e. immediate vs. delayed effects following a single bout of RIPC) and the frequency of RIPC. Limited evidence in humans has demonstrated that repeated bouts of RIPC over several days uniquely improves vascular function beyond that observed with a single bout alone. Since changes in resistance vessel and microvascular function often precede symptoms and diagnosis of cardiovascular disease, repeated bouts of RIPC may be promising as a preclinical intervention to prevent or delay cardiovascular disease progression.
Topics: Animals; Cardiovascular Diseases; Heart; Humans; Ischemia; Ischemic Preconditioning; Reperfusion Injury
PubMed: 35596644
DOI: 10.1113/JP282568 -
Journal of Vascular Surgery May 2021The optimal techniques to manage acute limb ischemia (ALI) remain unclear. Previous reports have suggested that the decreased morbidity and mortality of endovascular...
BACKGROUND
The optimal techniques to manage acute limb ischemia (ALI) remain unclear. Previous reports have suggested that the decreased morbidity and mortality of endovascular approaches are mitigated by the limited technical success rates relative to open or hybrid approaches for ALI. However, these data failed to include newer technologies that might improve the technical success rates. We, therefore, sought to describe the current outcomes for an endovascular-first approach to ALI.
METHODS
We performed a single-center, single-arm, retrospective cohort study of consecutive patients with ALI from 2015 to 2018. Technical success, limb salvage, survival, patency, and length of stay were quantified using Kaplan-Meier (KM) analysis. Cox regression analysis was used to identify the predictors of amputation-free survival.
RESULTS
During the 3 years, 60 consecutive patients (39 men [65%]; median age, 65 years) presented with ALI. The Rutherford class was I in 15 patients (25%), IIa in 23 (38%), IIb in 13 (22%), and III in 9 patients (15%). Of the 60 patients, 34 had a history of previous failed ipsilateral revascularization (56%), including open bypass for 8 (13%), endovascular for 8 (13%), and both open and endovascular intervention for 18 (30%). The endovascular-first approach procedures included catheter-directed thrombolysis only (n = 19; 3%), catheter-directed thrombolysis plus aspiration and/or rheolytic thrombectomy (n = 19; 32%), and aspiration and/or rheolytic thrombectomy (n = 16; 26%). Six patients (10%) underwent covered stent placement only. The underlying occlusive process was most often thrombosis of a previous bypass graft or stent in 32 patients (53%), followed by native vessel thrombosis in 15 (25%). ALI had resulted from embolism in 13 patients (21.7%), including 2 (3%) with embolization to occlude a previous bypass graft or stent. Technical success was achieved in 58 patients (97%), with open conversion required in two patients (3%). At 30 days postoperatively, 52 patients (87%) survived, and 53 (88%) had successful limb salvage. Five patients (8%) had required four-compartment fasciotomy. No major hemorrhagic complications developed. The median length of stay overall and in the intensive care unit was 9 days (interquartile range, 4-14 days) and 2 days (interquartile range, 1-5 days), respectively. At 1 year, the KM estimates were as follows: amputation-free survival, 58% ± 0.08%; limb salvage, 74.3% ± 0.07%; and survival, 73.3% ± 0.07%. The 1-year KM estimates for primary and secondary patency were 39.4% ± 0.08% and 78.2% ± 0.07%, respectively. On multivariable Cox regression analysis, only age independently predicted for death and/or amputation at the last follow-up (hazard ratio, 1.06; 95% confidence interval, 1.01-1.10; P = .01).
CONCLUSIONS
The current endovascular approaches to ALI have high technical success rates. Survival, limb salvage, perioperative complications, and length of stay were similar to those from previous reports of historical open cohorts. Further prospective, appropriately powered, multicenter cohort studies are warranted to evaluate the efficacy of endovascular vs open approaches to ALI.
Topics: Acute Disease; Aged; Amputation, Surgical; Endovascular Procedures; Female; Humans; Ischemia; Length of Stay; Limb Salvage; Male; Middle Aged; Peripheral Arterial Disease; Progression-Free Survival; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Vascular Patency
PubMed: 33068768
DOI: 10.1016/j.jvs.2020.10.002 -
Journal of the American Heart... Nov 2021Background Ankle-brachial index (ABI) is used to identify lower-extremity peripheral artery disease (PAD). However, its association with severe ischemic leg outcomes...
Background Ankle-brachial index (ABI) is used to identify lower-extremity peripheral artery disease (PAD). However, its association with severe ischemic leg outcomes (eg, amputation) has not been investigated in the general population. Methods and Results Among 13 735 ARIC (Atherosclerosis Risk in Communities) study participants without clinical manifestations of PAD (mean age, 54 [SD, 5.8] years; 44.4% men; and 73.6% White) at baseline (1987-1989), we quantified the prospective association between ABI and subsequent severe ischemic leg outcomes, critical limb ischemia (PAD with rest pain or tissue loss) and ischemic leg amputation (PAD requiring amputation) according to discharge diagnosis. Over a median follow-up of ≈28 years, there were 221 and 129 events of critical limb ischemia and ischemic leg amputation, respectively. After adjusting for demographics, ABI ≤0.90 versus 1.11 to 1.20 had a ≈4-fold higher risk of critical limb ischemia and ischemic leg amputation (hazard ratios, 3.85 [95% CI, 2.09-7.11] and 4.39 [95% CI, 2.08-9.27]). The magnitude of the association was modestly attenuated after multivariable adjustment (hazard ratios, 2.44 [95% CI, 1.29-4.61] and 2.72 [95% CI, 1.25-5.91], respectively). ABI 0.91 to 1.00 and 1.01 to 1.10 were also associated with these severe leg outcomes, with hazard ratios ranging from 1.7 to 2.0 after accounting for potential clinical and demographic confounders. The associations were largely consistent across various subgroups. Conclusions In a middle-aged community-based cohort, lower ABI was independently and robustly associated with increased risk of severe ischemic leg outcomes. Our results further support ABI ≤0.90 as a threshold diagnosing PAD and also suggest the importance of recognizing the prognostic value of ABI 0.91 to 1.10 for limb prognosis.
Topics: Ankle Brachial Index; Chronic Limb-Threatening Ischemia; Female; Humans; Ischemia; Leg; Male; Middle Aged; Peripheral Arterial Disease; Risk Factors
PubMed: 34726067
DOI: 10.1161/JAHA.121.021801 -
Surgery Mar 2023Mechanical circulatory support effectively treats adult cardiogenic shock. Whereas cardiogenic shock confers high mortality, acute limb ischemia is a known complication...
Peripherally inserted concomitant surgical right and left ventricular support, the Propella, is associated with low rates of limb ischemia, with mortality comparable with peripheral venoarterial extracorporeal membrane oxygenation.
BACKGROUND
Mechanical circulatory support effectively treats adult cardiogenic shock. Whereas cardiogenic shock confers high mortality, acute limb ischemia is a known complication of mechanical circulatory support that confers significant morbidity. We compared our novel approach to peripheral mechanical circulatory support with a conventional femoral approach, with a focus on the incidence of acute limb ischemia.
METHODS
This was a retrospective cohort study of patients treated with mechanical circulatory support between January 1, 2015 and December 5, 2021 at our institution. Patients receiving any femoral peripheral venoarterial extracorporeal membrane oxygenation were compared with those receiving minimally invasive, peripherally inserted, concomitant right and left ventricular assist devices. These included the Impella 5.0 (Abiomed, Danvers, MA) left ventricular assist device and the ProtekDuo (LivaNova, London, UK) right ventricular assist device used concomitantly (Propella) approach. The primary outcome was incidence of acute limb ischemia. The baseline patient characteristics, hemodynamic data, and post-mechanical circulatory support outcomes were collected. Fisher exact test and Wilcoxon rank sum test was used for the categorical and continuous variables, respectively. Kaplan-Meier curves and log-rank test were used to estimate overall survival probabilities and survival experience, respectively.
RESULTS
Fifty patients were treated with mechanical circulatory support at our institution for cardiogenic shock, with 13 patients supported with the novel Propella strategy and 37 with peripheral venoarterial extracorporeal membrane oxygenation. The baseline characteristics, including patient organ function and medical comorbidities, were similar among the groups. Nine patients suffered mortality in ≤48 hours of mechanical circulatory support initiation and were excluded. Twenty patients (69%) suffered acute limb ischemia in the peripheral venoarterial extracorporeal membrane oxygenation group; 0 patients receiving Propella suffered acute limb ischemia (P < .001). The percentages of patients surviving to discharge in peripheral venoarterial extracorporeal membrane oxygenation and Propella groups were 24% and 69%, respectively (P = .007).
CONCLUSION
Patients treated with the Propella experienced a lower incidence of acute limb ischemia compared with patients treated with peripheral venoarterial extracorporeal membrane oxygenation.
Topics: Adult; Humans; Shock, Cardiogenic; Retrospective Studies; Extracorporeal Membrane Oxygenation; Ischemia; Heart-Assist Devices
PubMed: 36435648
DOI: 10.1016/j.surg.2022.10.007