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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 -
Frontiers in Endocrinology 2023Heel ulcer is one of the severe complications of patients with diabetes mellitus, which poses a high risk for foot infection and amputation, especially in patients with...
Heel ulcer is one of the severe complications of patients with diabetes mellitus, which poses a high risk for foot infection and amputation, especially in patients with peripheral arterial disease and neuropathy. Researchers have searched for new treatments for treating diabetic foot ulcers in recent years. In this case report, we demonstrated the treatment of large ischemic ulcers for the first time in a diabetic patient. The overall treatment goal of this patient was designed to improve blood supply to her diseased lower extremities and close the ulcer. This two-stage reconstruction approach resulted in an ulcer-free, stable, plantigrade foot at postoperative follow-up.
Topics: Humans; Female; Heel; Wound Healing; Diabetic Foot; Peripheral Arterial Disease; Amputation, Surgical; Ischemia; Diabetes Mellitus
PubMed: 37396178
DOI: 10.3389/fendo.2023.1198818 -
Journal of Vascular Surgery Apr 2021Few studies adequately evaluate the impact of wound location on patient outcomes after lower extremity revascularization. Consequently, we evaluated the relationship... (Comparative Study)
Comparative Study
OBJECTIVE
Few studies adequately evaluate the impact of wound location on patient outcomes after lower extremity revascularization. Consequently, we evaluated the relationship between lower extremity wound location and long-term outcomes.
METHODS
We reviewed all patients at our institution undergoing any first-time open surgical bypass or percutaneous transluminal angioplasty with or without stenting for tissue loss between 2005 and 2014. We categorized wounds into three distinct groups: forefoot (ie, toes and metatarsal heads), midfoot (ie, dorsal, plantar, lateral, medial surfaces excluding toes, metatarsal heads, or heel), and heel. Limbs with multiple wounds were excluded from analyses. We compared rates of perioperative complications, wound healing, reintervention, limb salvage, amputation-free survival, and survival using χ, Kaplan-Meier, and Cox regression analyses.
RESULTS
Of 2869 infrainguinal revascularizations from 2005 to 2014, 1126 underwent a first-time revascularization for tissue loss, of which 253 patients had multiple wounds, 197 had wounds proximal to the ankle, 100 had unreliable wound information, and 576 (forefoot, n = 397; midfoot, n = 61; heel, n = 118) fit our criteria and had a single foot wound with reliable information regarding wound specifics. Patients with forefoot, midfoot, and heel wounds had similar rates of coronary artery disease, hypertension, diabetes, and smoking history (all P > .05). Conversely, there were significant differences in patient age (71 vs 69 vs 70 years), prevalence of gangrene (41% vs 5% vs 21%), and dialysis dependence (18% vs 17% vs 30%) (all P < .05). There were no statistically significant differences in perioperative mortality (1.3% vs 4.9% vs 4.2%; P = .06) or postoperative complications among the three groups. Between forefoot, midfoot, and heel wounds, there were significant differences in unadjusted 6-month rates of complete wound healing (69% vs 64% vs 53%), 3-year rates of amputation-free survival (54% vs 57% vs 35%), and survival (61% vs 72% vs 41%) (all P < .05). After adjustment, compared with forefoot wounds, heel wounds were associated with higher rates of incomplete 6-month wound healing (hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.1-2.]), major amputation or mortality (HR, 1.7; 95% CI, 1.1-2.7), and all-cause mortality (HR, 1.8; 95% CI, 1.1-3.0), but not major amputation alone (HR, 2.1; 95% CI, 0.9-4.5). In open surgical bypass-first patients, heel wounds were solely associated with an increased risk of all-cause mortality (HR, 1.7; 95% CI, 1.1-2.8), whereas heel wounds in percutaneous transluminal angioplasty-first patients were associated with an increased risk of incomplete wound healing (HR, 2.2; 95% CI, 1.3-3.7), major amputation or mortality (HR, 2.3; 95% CI, 1.1-5.4), and all-cause mortality (HR, 2.8; 95% CI, 1.1-7.2).
CONCLUSIONS
Heel wounds confer considerably higher short- and long-term morbidity and mortality compared with midfoot or forefoot wounds in patients undergoing any first-time lower extremity revascularization.
Topics: Aged; Aged, 80 and over; Amputation, Surgical; Angioplasty; Blood Vessel Prosthesis Implantation; Databases, Factual; Female; Humans; Ischemia; Limb Salvage; Lower Extremity; Male; Middle Aged; Peripheral Arterial Disease; Retrospective Studies; Risk Assessment; Risk Factors; Saphenous Vein; Stents; Time Factors; Treatment Outcome; Wound Healing
PubMed: 32866559
DOI: 10.1016/j.jvs.2020.07.091 -
Journal of Vascular Surgery May 2021The Superficial Femoral Artery-Popliteal EvidencE Development Study Group developed contemporary objective performance goals (OPGs) for peripheral vascular interventions...
BACKGROUND
The Superficial Femoral Artery-Popliteal EvidencE Development Study Group developed contemporary objective performance goals (OPGs) for peripheral vascular interventions (PVI) for superficial femoral artery (SFA)-popliteal artery disease using the Registry Assessment of Peripheral Interventional Devices.
METHODS
The Society for Vascular Surgery Vascular Quality Initiative PVI registry from January 2010 to October 2016 was used to develop OPGs based on SFA-popliteal procedures (n = 21,377) for intermittent claudication and critical limb ischemia (CLI). OPGs included 1-year rates for target lesion revascularization (TLR), major amputation, and 1 and 4-year survival rates. OPGs were calculated for the SFA and popliteal arteries and stratified by four treatments: angioplasty alone (percutaneous transluminal angioplasty [PTA]), self-expanding stenting, atherectomy, and any treatment type. Outcomes were illustrated by unadjusted Kaplan-Meier analyses.
RESULTS
Cohorts included PTA (n = 7505), stenting (n = 9217), atherectomy (n = 2510) and any treatment (n = 21,377). The mean age was 69 years, 58% were male, 79% were White, and 52% had CLI. The freedom from TLR OPGs at 1 year in the SFA were 80.3% (PTA), 83.2% (stenting), 83.9% (atherectomy), and 81.9% (any treatments). The freedom from TLR OPGs at 1 year in the popliteal were 81.3% (PTA), 81.3% (stenting), 80.2% (atherectomy), and 81.1% (any treatments). The freedom from major amputation OPGs at 1 year after SFA PVI were 93.4% (PTA), 95.7% (stenting), 95.1% (atherectomy), and 94.8% (any treatments). The freedom from major amputation OPG at 1 year after popliteal PVI were 90.5% (PTA), 93.7% (stenting), 91.8% (atherectomy), and 91.8%, (any treatments). The 4-year survival OPGs after SFA PVI were 76% (PTA), 80% (stenting), 82% (atherectomy), and 79% (any treatments), and for the popliteal artery were 72% (PTA), 77% (stenting), 82% (atherectomy), and 75% (any treatment). On a multivariable analysis, which included patient-level, leg-level, and lesion-level covariates, CLI was the single independent factor associated with increased TLR, amputation, and mortality.
CONCLUSIONS
The Superficial Femoral Artery-Popliteal EvidencE Development OPGs define a new, contemporary benchmark for SFA-popliteal interventions using a large subset of real-world evidence to inform more efficient peripheral device clinical trial designs to support regulatory and clinical decision-making. It is appropriate to discuss proposals intended for regulatory approval with the US Food and Drug Administration to refine the OPG to match the specific trial population. The OPGs may be updated using coordinated registry networks to assess long-term real-world device performance.
Topics: Aged; Aged, 80 and over; Amputation, Surgical; Benchmarking; Critical Illness; Endovascular Procedures; Female; Femoral Artery; Hospital Mortality; Humans; Intermittent Claudication; Ischemia; Limb Salvage; Male; Middle Aged; Peripheral Arterial Disease; Popliteal Artery; Quality Indicators, Health Care; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; United States
PubMed: 33080324
DOI: 10.1016/j.jvs.2020.09.030 -
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 -
Journal of Cardiovascular Translational... Dec 2021Currently, there is no large animal model of sustained limb ischemia suitable for testing novel angiogenic therapeutics for peripheral artery disease (PAD) such as...
Currently, there is no large animal model of sustained limb ischemia suitable for testing novel angiogenic therapeutics for peripheral artery disease (PAD) such as drugs, genes, materials, or cells. We created a large animal model suitable for efficacy assessment of these therapies by testing 3 swine hind limb ischemia (HLI) variations and quantifying vascular perfusion, muscle histology, and limb function. Ligation of the ipsilateral external and bilateral internal iliac arteries produced sustained gait dysfunction compared to isolated external iliac or unilateral external and internal iliac artery ligations. Hyperemia-dependent muscle perfusion deficits, depressed limb blood pressure, arteriogenesis, muscle atrophy, and microscopic myopathy were quantifiable in ischemic limbs 6 weeks post-ligation. Porcine mesenchymal stromal cells (MSCs) engineered to express a reporter gene were visualized post-administration via positron emission tomography (PET) in vivo. These results establish a preclinical platform enabling better optimization of PAD therapies, including cellular therapeutics, increasing bench-to-bedside translational success. A preclinical platform for porcine studies of peripheral artery disease therapies including (1) a hind limb ischemia model and (2) non-invasive MSC viability and retention assessment via PET.
Topics: Animals; Disease Models, Animal; Hindlimb; Ischemia; Peripheral Arterial Disease; Regional Blood Flow; Swine
PubMed: 34050499
DOI: 10.1007/s12265-021-10134-8 -
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 -
Journal of Thermal Biology Feb 2023Current chronic limb threatening ischemia (CLTI) diagnostics require expensive equipment, using ionizing radiation or contrast agents, or summative surrogate methods...
OBJECTIVES
Current chronic limb threatening ischemia (CLTI) diagnostics require expensive equipment, using ionizing radiation or contrast agents, or summative surrogate methods lacking in spatial information. Our aim is to develop and improve contactless, non-ionizing and cost-effective diagnostic methods for CLTI assessment with high spatial accuracy by utilizing dynamic thermal imaging and the angiosome concept.
APPROACH
Dynamic thermal imaging test protocol was suggested and implemented with a number of computational parameters. Pilot data was measured from 3 healthy young subjects, 4 peripheral artery disease (PAD) patients and 4 CLTI patients. The protocol consists of clinical reference measurements, including ankle- and toe-brachial indices (ABI, TBI), and a modified patient bed for hydrostatic and thermal modulation tests. The data was analyzed using bivariate correlation.
RESULTS
The thermal recovery time constant was on average higher for the PAD (88%) and CLTI (83%) groups with respect to the healthy young subjects. The contralateral symmetry was high for the healthy young group and low for the CLTI group. The recovery time constants showed high negative correlation to TBI (ρ = -0.73) and ABI (ρ = -0.60). The relation of these clinical parameters to the hydrostatic response and absolute temperatures (|ρ|<0.3) remained unclear.
CONCLUSION
The lack of correlation for absolute temperatures or their contralateral differences with the clinical status, ABI and TBI disputes their use in CLTI diagnostics. Thermal modulation tests tend to augment the signs of thermoregulation deficiencies and accordingly high correlations were found with all reference metrics. The method is promising for establishing the connection between impaired perfusion and thermography. The hydrostatic modulation test requires more research with stricter test conditions.
Topics: Humans; Chronic Limb-Threatening Ischemia; Ischemia; Lower Extremity; Peripheral Arterial Disease; Ankle; Risk Factors; Retrospective Studies
PubMed: 36796912
DOI: 10.1016/j.jtherbio.2023.103467 -
Journal of Vascular Surgery Nov 2021Paclitaxel (PTX)-coated peripheral arterial devices have been shown to decrease femoropopliteal artery restenosis and the need for reintervention compared with...
OBJECTIVE
Paclitaxel (PTX)-coated peripheral arterial devices have been shown to decrease femoropopliteal artery restenosis and the need for reintervention compared with non-PTX-coated devices. The data regarding PTX efficacy and safety come from randomized controlled trials that almost exclusively enrolled patients with claudication. The outcomes of PTX treatment in patients who present with chronic limb-threatening ischemia (CLTI) are unknown. This study compares long-term outcomes in patients with CLTI treated with and without PTX.
METHODS
We retrospectively reviewed 983 patients with CLTI treated with femoropopliteal artery angioplasty, atherectomy, stent, or combination between 2011 and 2019. Procedures were performed with additional proximal or distal tibial interventions as needed. Kaplan-Meier survival analysis and multivariable Cox-regression analysis compared overall survival (OS), amputation-free survival (AFS), freedom from major amputation (ff-MA), and freedom from target vessel revascularization (ff-TVR) between patients treated with and without PTX.
RESULTS
Demographics, comorbidities, and Rutherford class were similar between 574 PTX (58.5%) and 409 non-PTX (41.6%) patients except that non-PTX patients were more likely to be male (56.2% vs 49.7%), dialysis dependent (19.6% vs 14.3%), and have higher average creatinine (2.3 vs 1.8 mg/dL). Through 4-year follow-up, the PTX group demonstrated a significant increase in OS (56.2% vs 43.9%, P = .013), AFS (52.6% vs 36.1%, P < .0001), ff-MA (87.4% vs 78.7%, P = .0007), and ff-TVR (77.6% vs 70.6%, P = .012). Multivariable Cox-regression analysis demonstrated that PTX treatment was associated with improved OS, AFS, ff-MA, and ff-TVR.
CONCLUSIONS
In patients with CLTI, treatment with a PTX-coated device is associated with improved OS, AFS, ff-MA, and ff-TVR through 4-year follow-up. PTX-coated devices may be especially beneficial in patients who present with CLTI.
Topics: Aged; Aged, 80 and over; Amputation, Surgical; Angioplasty, Balloon; Cardiovascular Agents; Chronic Disease; Coated Materials, Biocompatible; Equipment Design; Female; Humans; Ischemia; Limb Salvage; Male; Middle Aged; Paclitaxel; Peripheral Arterial Disease; Progression-Free Survival; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors
PubMed: 34090989
DOI: 10.1016/j.jvs.2021.05.035 -
Journal of Vascular Surgery Aug 2019Bilateral acute limb ischemia after endovascular aneurysm repair is extremely rare. We present the case of a 70-year-old man treated by endovascular aneurysm repair for...
Bilateral acute limb ischemia after endovascular aneurysm repair is extremely rare. We present the case of a 70-year-old man treated by endovascular aneurysm repair for a 7.9-cm asymptomatic infrarenal abdominal aortic aneurysm using a bifurcated modular GORE EXCLUDER endoprosthesis (W. L. Gore & Associates, Flagstaff, Ariz). The initial recovery was uneventful, but 14 days later, the patient presented with bilateral acute limb ischemia caused by collapse and thrombosis of the endograft, requiring emergency axillobifemoral bypass, fasciotomies, and subsequent endograft removal with open aneurysm repair. The patient had no other complications at 7 months of follow-up. Oversizing of a GORE EXCLUDER graft because of a conical neck, a small bird-beak configuration, and a long angulated neck with aortoiliac tortuosity were potential contributing factors to endograft infolding and collapse.
Topics: Aged; Aortic Aneurysm, Abdominal; Blood Vessel Prosthesis; Blood Vessel Prosthesis Implantation; Device Removal; Endovascular Procedures; Graft Occlusion, Vascular; Humans; Ischemia; Male; Peripheral Arterial Disease; Prosthesis Design; Prosthesis Failure; Reoperation; Thrombosis; Treatment Outcome
PubMed: 30922762
DOI: 10.1016/j.jvs.2018.12.049