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European Heart Journal May 2022The prevalence of chronic limb-threatening ischaemia (CLTI) is increasing and available data often derive from cohorts with various selection criteria. In the present...
AIMS
The prevalence of chronic limb-threatening ischaemia (CLTI) is increasing and available data often derive from cohorts with various selection criteria. In the present study, we included CLTI patients and studied sex-related differences in their risk profile, vascular procedures, and long-term outcome.
METHODS AND RESULTS
We analysed 199 953 unselected patients of the largest public health insurance in Germany (AOK: Local healthcare funds), hospitalized between 2010 and 2017 for a main diagnosis of CLTI. A baseline period of 2 years before index hospitalization to assess comorbidities and previous procedures, and a follow-up period until 2018 were included. Female CLTI patients were older (median 81.4 vs. 73.8 years in males; P < 0.001) and more often diagnosed with hypertension, atrial fibrillation, chronic heart failure, and chronic kidney disease. Male patients suffered more frequently from diabetes mellitus, dyslipidaemia, smoking, cerebrovascular disease, and chronic coronary syndrome (all P < 0.001). Within hospitalized CLTI patients, females represent the minority (43% vs. 57%; P < 0.001) and during index hospitalization, women underwent less frequently diagnostic angiographies (67 vs. 70%) and revascularization procedures (61 vs. 65%; both P < 0.001). Moreover, women received less frequently guideline-recommended drugs like statins (35 vs. 43%) and antithrombotic therapy (48 vs. 53%; both P < 0.001) at baseline. Interestingly, after including age and comorbidities in a Cox regression analysis, female sex was associated with increased overall-survival (OS) [hazard ratio (HR) 0.95; 95% confidence interval (CI) 0.94-0.96] and amputation-free survival (AFS) (HR 0.84; 95% CI 0.83-0.85; both P < 0.001).
CONCLUSION
Female patients with CLTI were older, underwent less often vascular procedures, and received less frequently guideline-recommended medication. Nevertheless, female sex was independently associated with better OS and AFS during follow-up.
Topics: Amputation, Surgical; Chronic Disease; Chronic Limb-Threatening Ischemia; Female; Humans; Ischemia; Male; Peripheral Arterial Disease; Progression-Free Survival; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome
PubMed: 35134893
DOI: 10.1093/eurheartj/ehac016 -
Journal of Diabetes Research 2021Management of neuropathic pain in people with diabetes has been widely investigated. However, little attention was paid to address ischemic-related pain in patients with... (Review)
Review
Management of neuropathic pain in people with diabetes has been widely investigated. However, little attention was paid to address ischemic-related pain in patients with diabetes mellitus who suffered from chronic limb-threatening ischemia (CLTI), the end stage of lower extremity arterial disease (LEAD). Pain management has a tremendous influence on patients' quality of life and prognosis. Poor management of this type of pain owing to the lack of full understanding undermines patients' physical and mental quality of life, which often results in a grim prognosis, such as depression, myocardial infarction, lower limb amputation, and even mortality. In the present article, we review the current strategy in the pain management of diabetes-related CLTI. The endovascular therapy, pharmacological therapies, and other optional methods could be selected following comprehensive assessments to mitigate ischemic-related pain, in line with our current clinical practice. It is very important for clinicians and patients to strengthen the understanding and build intervention strategy in ischemic pain management and possible adverse consequence.
Topics: Chronic Disease; Diabetes Mellitus; Humans; Ischemia; Pain Management; Peripheral Arterial Disease; Quality of Life; Risk Factors; Treatment Outcome
PubMed: 34046505
DOI: 10.1155/2021/6699292 -
Artificial Organs Nov 2022Extracorporeal life support (ECLS) is a salvage treatment for acute circulatory failure. Our high-volume tertiary centre performs more than 100 implants annually and...
BACKGROUND
Extracorporeal life support (ECLS) is a salvage treatment for acute circulatory failure. Our high-volume tertiary centre performs more than 100 implants annually and provides ECLS-transports. With this study, we aimed to analyze the incidence and risk factors of limb ischemia depending on the vascular access.
METHODS
Between January 1, 2007, and December 31, 2018, 937 patients received an ECLS. Preoperative, intraoperative, in-hospital and up to 5 years follow-up data were collected. Outcome measures were limb ischemia and survival.
RESULTS
In total, 402 femoro-femoral veno-arterial ECLS patients were identified. Mean age was 56 ± 16.7 years, 26.9% were female, 7.9% had a history of peripheral vascular disease. Cannulation was performed percutaneously in 82.1% (n = 330), surgically in 5.7% (n = 23) and combined in 12.2% (n = 49). Mortality was not significantly different between the groups (51.1% percutaneous, 43.5% surgical, 44.9% combined [p = 0.89]). There was no significant difference in limb ischemia either, but a trend toward an increased frequency in the percutaneous group (p = 0.0501). No amputation was necessary. Limb ischemia slightly increased in-hospital mortality (54.6%) but did not affect long-term survival beyond 30 days. Univariate analysis adjusted for cannulation methods revealed younger age and female gender as risk factors of limb ischemia and younger age for limb ischemia after percutaneous cannulation.
CONCLUSIONS
Our study shows that percutaneous, surgical, and combined vascular access techniques for ECLS implantation are associated with comparable and low incidence of limb ischemia which slightly increases in-hospital mortality. Special precaution has to be taken in young and female patients.
Topics: Humans; Female; Adult; Middle Aged; Aged; Male; Extracorporeal Membrane Oxygenation; Catheterization, Peripheral; Femoral Artery; Retrospective Studies; Ischemia; Peripheral Vascular Diseases; Risk Factors
PubMed: 35723219
DOI: 10.1111/aor.14344 -
VASA. Zeitschrift Fur Gefasskrankheiten Jul 2023
Topics: Humans; Chronic Limb-Threatening Ischemia; Treatment Outcome; Risk Factors; Endovascular Procedures; Ischemia; Limb Salvage; Peripheral Arterial Disease; Retrospective Studies; Chronic Disease
PubMed: 37394924
DOI: 10.1024/0301-1526/a001078 -
Journal of Vascular Surgery Oct 2023Anticipated perioperative morbidity is an important factor for choosing a revascularization method for chronic limb-threatening ischemia (CLTI). Our goal was to assess... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
Anticipated perioperative morbidity is an important factor for choosing a revascularization method for chronic limb-threatening ischemia (CLTI). Our goal was to assess systemic perioperative complications of patients treated with surgical and endovascular revascularization in the Best Endovascular vs Best Surgical Therapy in Patients with CLTI (BEST-CLI) trial.
METHODS
BEST-CLI was a prospective randomized trial comparing open (OPEN) and endovascular (ENDO) revascularization strategies for patients with CLTI. Two parallel cohorts were studied: Cohort 1 included patients with adequate single-segment great saphenous vein (SSGSV), whereas Cohort 2 included those without SSGSV. Data were queried for major adverse cardiovascular events (MACE-composite myocardial infarction, stroke, death), non-serious (non-SAEs) and serious adverse events (SAEs) (criteria-death/life-threatening/requiring hospitalization or prolongation of hospitalization/significant disability/incapacitation/affecting subject safety in trial) 30 days after the procedure. Per protocol analysis was used (intervention received without crossover), and risk-adjusted analysis was performed.
RESULTS
There were 1367 patients (662 OPEN, 705 ENDO) in Cohort 1 and 379 patients (188 OPEN, 191 ENDO) in Cohort 2. Thirty-day mortality in Cohort 1 was 1.5% (OPEN 1.8%; ENDO 1.3%) and in Cohort 2 was 1.3% (2.7% OPEN; 0% ENDO). MACE in Cohort 1 was 4.7% for OPEN vs 3.13% for ENDO (P = .14), and in Cohort 2, was 4.28% for OPEN and 1.05% for ENDO (P = .15). On risk-adjusted analysis, there was no difference in 30-day MACE for OPEN vs ENDO for Cohort 1 (hazard ratio [HR] 1.5; 95% confidence interval [CI], 0.85-2.64; P = .16) or Cohort 2 (HR, 2.17; 95% CI, 0.48-9.88; P = .31). The incidence of acute renal failure was similar across interventions; in Cohort 1 it was 3.6% for OPEN vs 2.1% for ENDO (HR, 1.6; 95% CI, 0.85-3.12; P = .14), and in Cohort 2, it was 4.2% OPEN vs 1.6% ENDO (HR, 2.86; 95% CI, 0.75-10.8; P = .12). The occurrence of venous thromboembolism was low overall and was similar between groups in Cohort 1 (OPEN 0.9%; ENDO 0.4%) and Cohort 2 (OPEN 0.5%; ENDO 0%). Rates of any non-SAEs in Cohort 1 were 23.4% in OPEN and 17.9% in ENDO (P = .013); in Cohort 2, they were 21.8% for OPEN and 19.9% for ENDO (P = .7). Rates for any SAEs in Cohort 1 were 35.3% for OPEN and 31.6% for ENDO (P = .15); in Cohort 2, they were 25.5% for OPEN and 23.6% for ENDO (P = .72). The most common types of non-SAEs and SAEs were infection, procedural complications, and cardiovascular events.
CONCLUSIONS
In BEST-CLI, patients with CLTI who were deemed suitable candidates for open lower extremity bypass surgery had similar peri-procedural complications following either OPEN or ENDO revascularization: In such patients, concern about risk of peri-procedure complications should not be a deterrent in deciding revascularization strategy. Rather, other factors, including effectiveness in restoring perfusion and patient preference, are more relevant.
Topics: Humans; Chronic Limb-Threatening Ischemia; Prospective Studies; Risk Factors; Endovascular Procedures; Peripheral Arterial Disease; Limb Salvage; Ischemia; Lower Extremity; Treatment Outcome; Retrospective Studies
PubMed: 37318428
DOI: 10.1016/j.jvs.2023.05.040 -
Scandinavian Journal of Surgery : SJS :... Jun 2021Because chronic limb-threatening ischemia (CLTI) is often associated with multilevel arterial disease, it usually requires revascularization at different sites of the...
BACKGROUND AND AIMS
Because chronic limb-threatening ischemia (CLTI) is often associated with multilevel arterial disease, it usually requires revascularization at different sites of the limb vasculature. We aim to assess the outcome of the hybrid interventions including open surgical revascularization together with outflow segment percutaneous transluminal angioplasty (PTA) in patients with chronic limb-threatening ischemia.
MATERIAL AND METHODS
This study included all hybrid outflow-PTA interventions (n = 80) on patients suffering from CLTI performed in Helsinki University Hospital between 2003 and 2015. Follow-up ended on 31 December 2019. Patient data were prospectively collected into our vascular registry and scrutinized retrospectively. Thirty-one patients (39%) suffered from rest pain (Rutherford category IV) and 49 patients (61%) had ischemic ulcers (Rutherford category V-VI). The most common open surgical procedure was femoral endarterectomy (n = 63, 79%) and the most common endovascular procedure was superficial femoral artery percutaneous transluminal angioplasty (n = 65, 81%). Mean follow-up time was 56 months (range: 4 days-183 months).
RESULTS
Limb salvage was at 30 days-92%, at 1 year-91%, and at 5 and 10 years-86%. Survival and amputation-free survival were at 30 days-93% and 86%, at 1 year-80% and 76%, at 5 years-51% and 48%, and at 10 years-21% and 21%. Wound healing at 3, 6, and 12 months was 48%, 71%, and 87%. Freedom from target lesion revascularization was at 30 days-97%, at 1 year-88%, at 5 years-72%, and at 10 years-66%.
CONCLUSION
Hybrid outflow revascularization is an important tool in the vascular surgeon's armamentarium for treatment of patients with multilevel arterial disease causing chronic limb-threatening ischemia.
Topics: Amputation, Surgical; Chronic Limb-Threatening Ischemia; Endovascular Procedures; Humans; Ischemia; Limb Salvage; Peripheral Arterial Disease; Retrospective Studies; Risk Factors; Treatment Outcome; Vascular Patency
PubMed: 33308022
DOI: 10.1177/1457496920975608 -
Advances in Skin & Wound Care May 2021Norepinephrine is used in the acute care setting to establish and maintain hemodynamic stability in patients with hypotension. Although it is often a lifesaving...
Norepinephrine is used in the acute care setting to establish and maintain hemodynamic stability in patients with hypotension. Although it is often a lifesaving medication, norepinephrine may lead to profound vascular insufficiency in the extremities, resulting in dry gangrene and skin necrosis. The purpose of this article is to present a case series of skin complications related to treatment with norepinephrine and review the pathophysiology behind these complications. The authors also explore risk stratification as it relates to history and clinical presentation with subsequent focus on contingencies to mitigate the adverse effects of vasoconstriction on peripheral tissues.
Topics: Aged; Case-Control Studies; Female; Gangrene; Humans; Ischemia; Male; Middle Aged; Norepinephrine; Peripheral Vascular Diseases; Vasoconstrictor Agents
PubMed: 33852464
DOI: 10.1097/01.ASW.0000741528.49437.2c -
European Journal of Vascular and... Nov 2020
Topics: Amputation, Surgical; Cohort Studies; Humans; Ischemia; Peripheral Vascular Diseases; United Kingdom
PubMed: 32978051
DOI: 10.1016/j.ejvs.2020.08.029 -
The British Journal of Surgery Mar 2023
Topics: Humans; Chronic Disease; Chronic Limb-Threatening Ischemia; Ischemia; Peripheral Arterial Disease; Retrospective Studies; Risk Factors; Treatment Outcome
PubMed: 36638367
DOI: 10.1093/bjs/znac465 -
Vascular and Endovascular Surgery Jul 2022Chronic limb-threatening ischemia (CLTI) carries a high risk of amputation and warrants urgent intervention. CLTI involving the infrageniculate vessels, in particular,... (Review)
Review
Chronic limb-threatening ischemia (CLTI) carries a high risk of amputation and warrants urgent intervention. CLTI involving the infrageniculate vessels, in particular, carries a considerably higher risk of major limb amputation. Open surgical bypass is the historical gold standard for the treatment of tibial arterial disease; however, endovascular therapy provides an attractive alternative in this high-risk patient population. In this article, we review the existing literature regarding distal bypass and infrageniculate endovascular intervention in patients with CLTI.
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: 35356834
DOI: 10.1177/15385744221086347