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Scandinavian Journal of Surgery : SJS :... 2012This is a narrative review on vascular assessment for critical limb ischaemia in the past and present combining Finnish and Japanese experience. (Review)
Review
This is a narrative review on vascular assessment for critical limb ischaemia in the past and present combining Finnish and Japanese experience.
Topics: Ankle Brachial Index; Blood Gas Monitoring, Transcutaneous; Coloring Agents; Diabetic Foot; Finland; Foot; Humans; Indocyanine Green; Ischemia; Japan; Peripheral Vascular Diseases; Pulse; Ultrasonography, Doppler, Duplex
PubMed: 22623440
DOI: 10.1177/145749691210100203 -
International Angiology : a Journal of... Feb 2021Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a means of providing cardiopulmonary support that is being increasingly used in patients with acute heart...
BACKGROUND
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a means of providing cardiopulmonary support that is being increasingly used in patients with acute heart failure. When ECMO cannulae are placed peripherally, their large diameters pose a risk of limb ischemia. Distal perfusion cannulae (DPC) have been proposed as means to reduce risk, but their use is not recommended by the most recent ECMO guidelines. We sought to establish their utility at our institution.
METHODS
We performed a retrospective review of of all patients treated with peripheral VA-ECMO at our institution from 2013-2018. During the first 2 years, DPC were not routinely placed, whereas in the final 4 years, DPC were recommended as part of the ECMO cannulation routine.
RESULTS
One hundred and one patients were treated with peripheral VA-ECMO, with an overall mortality of 61%. By univariate analysis, obesity (47% vs. 75%, P<0.01) and limb ischemia (57% vs. 83%, P<0.05) were associated with increased mortality. DPC were placed prophylactically in 49% of patients. Prophylactic placement of a DPC at the time of cannulation significantly reduced the incidence of limb ischemia (2% vs. 32%, P<0.05), but did not impact mortality (53% vs. 69%, P=0.0953). In patients who did not have a DPC placed during ECMO cannulation and subsequently developed limb ischemia, late DPC placement for limb salvage did not impact mortality.
CONCLUSIONS
Limb ischemia portends a poor outcome in VA-ECMO patients, and prophylactic DPC placement significantly reduces the risk of limb ischemia. We propose prophylactic DPC placement be considered in patients requiring peripheral VA-ECMO.
Topics: Cannula; Catheterization, Peripheral; Extracorporeal Membrane Oxygenation; Femoral Artery; Humans; Ischemia; Perfusion; Retrospective Studies; Risk Factors
PubMed: 32996725
DOI: 10.23736/S0392-9590.20.04408-9 -
European Journal of Vascular and... Feb 2020
Topics: Acute Disease; Embolectomy; Endovascular Procedures; History, 16th Century; History, 17th Century; History, 19th Century; History, 20th Century; Humans; Ischemia; Leg; Peripheral Vascular Diseases; Treatment Outcome; Vascular Access Devices
PubMed: 31500991
DOI: 10.1016/j.ejvs.2019.07.032 -
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 -
European Journal of Pediatrics Aug 1992The aetiology of non-iatrogenic causes of peripheral ischaemia and gangrene presenting either at birth or within a few hours of delivery is unknown in the majority of 56... (Review)
Review
The aetiology of non-iatrogenic causes of peripheral ischaemia and gangrene presenting either at birth or within a few hours of delivery is unknown in the majority of 56 confirmed cases. In this review of 47 cases occurring since 1941 the aetiology was clear in only 6, four due to compression by the encircling umbilical cord. There was no clear association with gestational age, birth weight, maternal age or type of delivery. Seven were infants of poorly controlled diabetic mothers and these may constitute a subgroup due to altered haemostatic mechanisms. Pregnancy hypertension was an association in 7 cases, oligohydramnios in 6. There is only limited support for birth trauma, sepsis, and thrombo-emboli from the ductus arteriosus as causes. There is indirect evidence that thrombo-emboli can migrate from the placental bed to the fetus. In recent years death from this condition has been rare with surgical thrombectomy increasingly successful in late presenting cases. When gangrene is established at birth surgical amputation, autoamputation, or some loss of function is usual. Peripheral ischaemic insults presenting at birth may be part of a wider spectrum of disorders, both prenatal and perinatal, attributable to occlusive vascular disruption.
Topics: Extremities; Gangrene; Humans; Infant, Newborn; Ischemia
PubMed: 1505568
DOI: 10.1007/BF01957717 -
Drugs Nov 2012The generalized term 'peripheral vascular disease' (PVD) may be used to refer to vascular disorders in any non-coronary arterial bed. The more specific term 'peripheral... (Review)
Review
The generalized term 'peripheral vascular disease' (PVD) may be used to refer to vascular disorders in any non-coronary arterial bed. The more specific term 'peripheral arterial disease' (PAD) is used to refer to a more specific process, atherosclerotic disease of the lower extremities. PAD is common. Conservative estimates suggest more than 8 million Americans may be affected by PAD. Since atherosclerosis is a systemic process, PAD should be identified as a coronary heart disease risk equivalent. However, PAD remains an under-diagnosed and under-recognized risk for cardiovascular morbidity and mortality. PAD symptoms may range from non-specific ambulatory leg complaints, to typical symptoms of intermittent claudication to critical limb ischaemia with rest pain, gangrene or ulceration. These symptoms directly impact quality of life and may affect functional capacity. There are two therapeutic goals for patients with PAD: first, to reduce the risk of cardiovascular events and second, to manage the lower extremity symptoms. This manuscript reviews the medical management of patients with PAD, briefly discussing the goals of cardiovascular risk factor modification and then focusing on pharmacological management strategies for patients with intermittent claudication and critical limb ischaemia.
Topics: Atherosclerosis; Exercise Therapy; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors; Intermittent Claudication; Ischemia; Lower Extremity; Platelet Aggregation Inhibitors; Quality of Life; Randomized Controlled Trials as Topic; Risk Factors; Vascular Surgical Procedures; Vasodilator Agents
PubMed: 23046179
DOI: 10.2165/11640810-000000000-00000 -
European Journal of Vascular and... Apr 2024
Topics: Humans; Oxygen; Leg; Ischemia; Peripheral Vascular Diseases; Oxygen Inhalation Therapy; Acute Disease
PubMed: 38056521
DOI: 10.1016/j.ejvs.2023.12.004 -
Thrombosis and Haemostasis Apr 2010Atherosclerotic peripheral artery disease (PAD) is a common manifestation of atherosclerosis. The occlusion of large limb arteries leads to ischaemia with claudication... (Review)
Review
Atherosclerotic peripheral artery disease (PAD) is a common manifestation of atherosclerosis. The occlusion of large limb arteries leads to ischaemia with claudication which can progress to critical limb ischaemia (CLI) with pain at rest, and to tissue loss. At present, common therapy for CLI is either surgical or endovascular revascularisation aimed at improving blood flow to the affected extremity. However, major amputation and death are still frequent complications. Exploring new strategies for revascularisation of ischaemic limbs is thus of major importance. Bone marrow (BM)-derived stem and progenitor cells have been identified as a potential new therapeutic option to induce therapeutic angiogenesis. Encouraging results of preclinical studies have rapidly led to several small clinical trials, in which BM-derived mononuclear cells were administered to patients with limb ischaemia. Clinical benefits were reported from these trials including improvement of ankle-brachial index (ABI), transcutaneous partial pressure of oxygen (TcPO2), reduction of pain, and decreased need for amputation. Nonetheless, large randomised, placebo-controlled, double-blind studies are necessary and currently ongoing (BONMOT-CLI, JUVENTUS and NCT00498069). Further research relates to the optimal cell type and dosage, the isolation method, the role of colony-stimulating factors, administration route, and the supportive stimulation of cells with reduced functioning due to advanced PAD. Autologous stem cell therapy for ischaemic peripheral disease seems to be a promising new tool for the treatment of severe limb ischaemia. Preliminary evidence has established its safety, feasibility and effectiveness on several important endpoints. Several large endpoints studies are underway to further consolidate this evidence.
Topics: Animals; Collateral Circulation; Critical Illness; Disease Models, Animal; Evidence-Based Medicine; Humans; Ischemia; Lower Extremity; Microcirculation; Neovascularization, Physiologic; Peripheral Vascular Diseases; Randomized Controlled Trials as Topic; Recovery of Function; Regenerative Medicine; Regional Blood Flow; Stem Cell Transplantation; Time Factors; Transplantation, Autologous; Treatment Outcome
PubMed: 20174766
DOI: 10.1160/TH09-10-0688 -
Nature Reviews. Cardiology Jul 2013Peripheral arterial disease (PAD) is caused by occlusive atherosclerosis in a vascular bed other than the heart. The lower extremity is the most-common location for PAD.... (Review)
Review
Peripheral arterial disease (PAD) is caused by occlusive atherosclerosis in a vascular bed other than the heart. The lower extremity is the most-common location for PAD. Critical limb ischaemia (CLI) is the most-severe clinical manifestation of PAD. Despite improvements in medical care and revascularization, patients with CLI continue to have a high risk of major amputation (below the knee or higher) and cardiovascular death. The primary goal of therapy in CLI is to achieve blood flow to the distal limb vessels with angioplasty or bypass surgery. However, many patients with CLI are unsuitable for revascularization, or the procedure is unsuccessful. Angiogenesis is the growth and proliferation of blood vessels from an existing vascular structure. In therapeutic angiogenesis, attempts are made to utilize blood vessel growth to augment perfusion. In this Review, data from phase II and III clinical trials of therapeutic angiogenesis in patients with PAD will be presented and discussed. Potential explanations for the limited success of therapeutic angiogenesis in humans will be viewed in the context of advances in our understanding of the complex mechanisms underlying angiogenesis and vascular remodelling. This Review will also cover how advances in systems biology, genetics, and gene therapy might still allow the development of new approaches to therapeutic angiogenesis and achieve the goal of restoring perfusion.
Topics: Angiogenic Proteins; Critical Illness; Genetic Therapy; Hemodynamics; Humans; Ischemia; Lower Extremity; Neovascularization, Physiologic; Recovery of Function; Regional Blood Flow; Systems Biology; Treatment Outcome
PubMed: 23670612
DOI: 10.1038/nrcardio.2013.70 -
European Radiology 2001The technique of thrombolysis is now well established, becoming employed increasingly often in disease of the peripheral vasculature, both arterial and venous, in... (Review)
Review
The technique of thrombolysis is now well established, becoming employed increasingly often in disease of the peripheral vasculature, both arterial and venous, in addition to its important role in the treatment of coronary artery thrombosis. This is a general review of its applications in peripheral vascular disease causing acute lower limb ischaemia, currently the major indication for its use outside the coronary circulation.
Topics: Clinical Trials as Topic; Humans; Ischemia; Leg; Thrombolytic Therapy; Treatment Outcome
PubMed: 11288850
DOI: 10.1007/s003300000705