-
European Journal of Vascular and... Mar 2017Critical limb ischaemia (CLI) is the end stage of peripheral artery disease (PAD) and is associated with high amputation and mortality rates and poor quality of life.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Critical limb ischaemia (CLI) is the end stage of peripheral artery disease (PAD) and is associated with high amputation and mortality rates and poor quality of life. For CLI patients with no revascularisation options, venous arterialisation could be a last resort for limb salvage.
OBJECTIVE
To review the literature on the clinical effectiveness of venous arterialisation for lower limb salvage in CLI patients with no revascularisation options.
METHOD
Different databases were searched for papers published between January 1966 and January 2016. The criteria for eligible articles were studies describing outcomes of venous arterialisation, published in English, human studies, and with the full text available. Additionally, studies were excluded if they did not report limb salvage, wound healing or amputation as outcome measures. The primary outcome measure was post-operative limb salvage at 12 months. Secondary outcome measures were 30 day or in-hospital mortality, survival, patency, technical success, and wound healing.
RESULTS
Fifteen articles met the inclusion criteria. The included studies described 768 patients. According to the MINORS score, methodological quality was moderate to poor. The estimated pooled limb salvage rate at one year was 75% (0.75, 95% CI 0.70-0.81). Thirty day or in-hospital mortality was reported in 12 studies and ranged from 0 to 10%. Overall survival was reported in 10 studies and ranged from 54% to 100% with a mean follow-up ranging from 5 to 60 months. Six studies reported on patency of the venous arterialisations performed, with a range of 59-71% at 12 months.
CONCLUSION
In this systematic review on venous arterialisation in patients with non-reconstructable critical limb ischaemia, the pooled proportion of limb salvage at 12 months was 75%. Venous arterialisation could be a valuable treatment option in patients facing amputation of the affected limb; however, the current evidence is of low quality.
Topics: Adult; Aged; Aged, 80 and over; Amputation, Surgical; Critical Illness; Female; Humans; Ischemia; Limb Salvage; Lower Extremity; Male; Middle Aged; Risk Factors; Time Factors; Treatment Outcome; Vascular Patency; Vascular Surgical Procedures; Wound Healing
PubMed: 28027892
DOI: 10.1016/j.ejvs.2016.11.007 -
Annales de Dermatologie Et de... 2015Vascular acrosyndromes are associated with vasomotor disorders. They may be paroxysmal, like Raynaud's phenomenon, whitening of the fingers on exposure to cold, or...
Vascular acrosyndromes are associated with vasomotor disorders. They may be paroxysmal, like Raynaud's phenomenon, whitening of the fingers on exposure to cold, or erythromelalgia, a painful form of erythema induced by exposure to heat. Others are permanent or semi-permanent, such as acrocyanosis, chilblains, spontaneous haematoma of the fingers, acrocholose and digital ischaemia or necrosis. Diagnosis of the type of acrosyndrome at issue is based primarily on clinical examination and history-taking. Capillaroscopy and antinuclear antibody assay are key examinations essential for distinguishing between primary and secondary Raynaud's phenomenon and connective tissue disorders. Complete blood counts, screening for thyroid dysthyroidism, and antinuclear antibody assay can help distinguish between primary erythromelalgia and erythromelalgia secondary to a systemic disease, principally myeloproliferative syndrome. In the case of acrocyanosis, spontaneous digital haematomas and typical bilateral chilblains, examinations are of no value. For the other permanent and semi-permanent acrosyndromes such as digital ischaemia and purpuric or livedoid lesions, screening for arterial or thrombotic disease is necessary.
Topics: Algorithms; Chilblains; Fingers; Hematoma; Humans; Ischemia; Necrosis; Peripheral Vascular Diseases; Physical Examination
PubMed: 26169898
DOI: 10.1016/j.annder.2015.06.006 -
European Journal of Vascular and... Dec 2023
Topics: Humans; COVID-19; Ischemia; Leg; Peripheral Vascular Diseases; India
PubMed: 37660750
DOI: 10.1016/j.ejvs.2023.08.064 -
European Heart Journal Apr 2015Only few and historic studies reported a bad prognosis of peripheral arterial disease (PAD) and critical limb ischaemia (CLI). The contemporary state of treatment and... (Observational Study)
Observational Study
AIMS
Only few and historic studies reported a bad prognosis of peripheral arterial disease (PAD) and critical limb ischaemia (CLI). The contemporary state of treatment and outcomes should be assessed.
METHODS AND RESULTS
From the largest public health insurance in Germany, all in- and outpatient diagnosis and procedural data were retrospectively obtained from a cohort of 41 882 patients hospitalized due to PAD during 2009-2011, including a follow-up until 2013. Patients were classified in Rutherford categories 1-3 (n = 21 197), 4 (n = 5353), 5 (n = 6916), and 6 (n = 8416). The proportions of patients with classical risk factors such as hypertension, dyslipidaemia, and smoking declined with higher Rutherford categories (each P < 0.001) while diabetes, chronic kidney disease, and chronic heart failure increased (each P < 0.001). Angiographies and revascularizations were performed less often in advanced PAD (each P < 0.001). In-hospital amputations increased continuously from 0.5% in Rutherford 1-3 to 42% in Rutherford 6, as also myocardial infarctions, strokes, and deaths (each P < 0.001). Among 4298 amputated patients with CLI, 37% had not received any angiography or revascularization neither during index hospitalization nor the 24 months before. During follow-up (mean 1144 days), 7825 patients were amputated and 10 880 died. Kaplan-Meier models projected 4-year mortality risks of 18.9, 37.7, 52.2, and 63.5% in Rutherford 1-3, 4, 5, and 6, and for amputation of 4.6, 12.1, 35.3, and 67.3%, respectively. In multivariable Cox regression models, PAD categories were significant predictors of death, amputation, myocardial infarction, and stroke (each P < 0.001). Length of in-hospital stay (5.8 ± 6.7 days, 10.7 ± 11.1days, 15.2 ± 13.8 days and 22.1 ± 20.3 days; P < 0.001) and mean case costs (3662 ± 3186 €, 5316 ± 6139 €, 6021 ± 4892 €, and 8461 ± 8515 €; P < 0.001) increased continuously in Rutherford 1-3, 4, 5, and 6. While only 49% of the patients suffered from CLI, these produced 65% of in-hospital costs (141 million €), and 56% during follow-up (336 million €).
CONCLUSION
Regardless of recent advances in PAD treatment, current outcomes remain poor especially in CLI. Despite overwhelming evidence for reduction of limb loss by revascularization, CLI patients still received significantly less angiographies and revascularizations.
Topics: Amputation, Surgical; Endovascular Procedures; Female; Guideline Adherence; Hospitalization; Humans; Ischemia; Lower Extremity; Male; Middle Aged; Peripheral Arterial Disease; Practice Guidelines as Topic; Radiography; Reperfusion; Retrospective Studies; Treatment Outcome
PubMed: 25650396
DOI: 10.1093/eurheartj/ehv006 -
Cardiovascular Research Feb 2011Ischaemic tissue damage represents the ultimate form of tissue pathophysiology due to cardiovascular disease, which is the leading cause of morbidity and mortality... (Review)
Review
Ischaemic tissue damage represents the ultimate form of tissue pathophysiology due to cardiovascular disease, which is the leading cause of morbidity and mortality across the globe. A significant amount of basic research and clinical investigation has been focused on identifying cellular and molecular pathways to alleviate tissue damage and dysfunction due to ischaemia and subsequent reperfusion. Over many years, the gaseous molecule nitric oxide (NO) has emerged as an important regulator of cardiovascular health as well as protector against tissue ischaemia and reperfusion injury. However, clinical translation of NO therapy for these pathophysiological conditions has not been realized for various reasons. Work from our laboratory and several others suggests that a new form of NO-associated therapy may be possible through the use of nitrite anion (sodium nitrite), a prodrug which can be reduced to NO in ischaemic tissues. In this manner, nitrite anion serves as a highly selective NO donor in ischaemic tissues without substantially altering otherwise normal tissue. This surprising and novel discovery has reinvigorated hopes for effectively restoring NO bioavailability in vulnerable tissues while continuing to reveal the complexity of NO biology and metabolism within the cardiovascular system. However, some concerns may exist regarding the effect of nitrite on carcinogenesis. This review highlights the emergence of nitrite anion as a selective NO prodrug for ischaemic tissue disorders and discusses the potential therapeutic utility of this agent for peripheral vascular disease.
Topics: Animals; Humans; Ischemia; Neovascularization, Physiologic; Nitric Oxide; Peripheral Vascular Diseases; Prodrugs; Sodium Nitrite
PubMed: 20851809
DOI: 10.1093/cvr/cvq297 -
Nederlands Tijdschrift Voor Geneeskunde Feb 2019Peripheral arterial disease is a common condition in elderly patients. Cases of severe peripheral vascular disease can be treated with endovascular revascularization or...
BACKGROUND
Peripheral arterial disease is a common condition in elderly patients. Cases of severe peripheral vascular disease can be treated with endovascular revascularization or bypass surgery. An amputation may be necessary if revascularization treatments fail.
CASE DESCRIPTION
A 94-year-old woman with dementia, living in a nursing home, was referred to the vascular surgery team for a painful ulcer on the left foot. Revascularization fails and due to the infectious status, an above-the-knee amputation seems necessary. Family and physicians, however, opt for a conservative, palliative policy and in the next few weeks the infectious ulcer develops into mummification. The patient nonetheless experiences a good quality of life until she becomes bedridden because of pneumonia. She dies 11 months after she was diagnosed with critical limb ischaemia.
CONCLUSION
Adopting a conservative approach in elderly patients with severe peripheral arterial disease and dementia is a worthwhile alternative to amputation, and can achieve a reasonably good quality of life. Diaries maintained by family members can provide insight into the patient's quality of life.
Topics: Age Factors; Aged, 80 and over; Conservative Treatment; Fatal Outcome; Female; Foot Ulcer; Humans; Ischemia; Peripheral Arterial Disease; Quality of Life
PubMed: 30730689
DOI: No ID Found -
Vascular Medicine (London, England) Feb 2015Intermittent pneumatic compression (IPC) is designed to aid wound healing and limb salvage for patients with critical limb ischaemia who are not candidates for... (Review)
Review
Intermittent pneumatic compression (IPC) is designed to aid wound healing and limb salvage for patients with critical limb ischaemia who are not candidates for revascularisation. We conducted a systematic review of the literature to identify and critically appraise the evidence supporting its use in this population. A search was conducted in Embase, MEDLINE and clinical trial registries up to the end of March 2013. No date or language restrictions were applied. Quality assessment was performed by two people independently. Quality was assessed using the Cochrane risk of bias tool and the NICE case-series assessment tool. Two controlled before-and-after (CBA) studies and six case series were identified. One retrospective CBA study involving compression of the calf reported improved limb salvage and wound healing (OR 7.00, 95% CI 1.82 to 26.89, p<0.01). One prospective CBA study involving sequential compression of the foot and calf reported statistically significant improvements in claudication distances and SF-36 quality of life scores. No difference in all-cause mortality was found. Complications included pain associated with compression, as well as skin abrasion and contact rash as a result of the cuff rubbing against the skin. All studies had a high risk of bias. In conclusion, the limited available results suggest that IPC may be associated with improved limb salvage, wound healing and pain management. However, in the absence of additional well-designed analytical studies examining the effect of IPC in critical limb ischaemia, this treatment remains unproven.
Topics: Amputation, Surgical; Critical Illness; Exercise Test; Exercise Tolerance; Humans; Intermittent Claudication; Intermittent Pneumatic Compression Devices; Ischemia; Limb Salvage; Pain Measurement; Quality of Life; Recovery of Function; Surveys and Questionnaires; Time Factors; Treatment Outcome; Wound Healing
PubMed: 25270409
DOI: 10.1177/1358863X14552096 -
Diabetes/metabolism Research and Reviews Jan 2016The confluence of several chronic conditions--in particular ageing, peripheral artery disease, diabetes, and chronic kidney disease--has created a global wave of lower... (Review)
Review
The confluence of several chronic conditions--in particular ageing, peripheral artery disease, diabetes, and chronic kidney disease--has created a global wave of lower limbs at risk for major amputation. While frequently asymptomatic or not lifestyle limiting, at least 1% of the population has peripheral artery disease of sufficient severity to be limb threatening. To avoid the critical error of failing to diagnose ischaemia, all patients with diabetic foot ulcers and gangrene should routinely undergo physiologic evaluation of foot perfusion. Ankle brachial index is useful when measurable, but may be falsely elevated or not obtainable in as many as 30% of patients with diabetic foot ulcers primarily because of medial calcinosis. Toe pressures and skin perfusion pressures are applicable to such patients.
Topics: Arteriosclerosis Obliterans; Combined Modality Therapy; Congresses as Topic; Diabetic Angiopathies; Diabetic Foot; Endovascular Procedures; Evidence-Based Medicine; Foot; Gangrene; Humans; Ischemia; Leg; Limb Salvage; Precision Medicine; Recurrence; Regional Blood Flow; Severity of Illness Index; Stents; Vascular Grafting
PubMed: 26455728
DOI: 10.1002/dmrr.2753 -
Journal of Internal Medicine Oct 2013Critical limb ischaemia (CLI) is a severe form of peripheral arterial disease (PAD). CLI often causes disabling symptoms of pain and can lead to loss of the affected... (Review)
Review
Critical limb ischaemia (CLI) is a severe form of peripheral arterial disease (PAD). CLI often causes disabling symptoms of pain and can lead to loss of the affected limb. It is also associated with increased risk of myocardial infarction, stroke and death from cardiovascular disease. The aims of management in patients with CLI are to relieve ischaemic pain, heal ulcers, prevent limb loss, improve function and quality of life and prolong survival. Here, current evidence regarding the medical management of CLI is reviewed. Cardiovascular risk factors should be assessed in all patients with CLI; smoking cessation and treatment of hypertension, hyperlipidaemia and diabetes all reduce the mortality rate in those with PAD. Antiplatelet agents (either aspirin or clopidogrel) are recommended to reduce both the incidence of cardiovascular events and risk of arterial occlusion. By contrast, routine use of anticoagulation (either warfarin or heparin) is not recommended. Treatment of the limbs themselves is often more challenging. Prostanoids may have some efficacy for treating rest pain and for ulcer healing, and iloprost shows favourable results in reducing the risk of major amputations, but long-term follow-up data regarding disease progression are lacking. There is insufficient evidence to support the use of naftidrofuryl or cilostazol, and pentoxifylline is not beneficial. Furthermore, there is no evidence of proven benefit of hyperbaric oxygen. A number of angiogenic growth factors have been studied in Phase I studies and randomized controlled trials (RCTs). They appear to be safe, but efficacy results have been mixed. Treatment with stem cells also shows some potential from early trials, but further larger RCTs are needed to demonstrate clear benefit. Thrombolysis may be an alternative for patients who develop acute limb ischaemia and are unsuitable for surgical intervention. However, newer endovascular techniques are likely to have a greater role in the future.
Topics: Anticoagulants; Arterial Occlusive Diseases; Cardiovascular Diseases; Humans; Ischemia; Lower Extremity; Peripheral Arterial Disease; Platelet Aggregation Inhibitors; Randomized Controlled Trials as Topic; Risk Factors
PubMed: 23795817
DOI: 10.1111/joim.12102 -
The Cochrane Database of Systematic... 2000Peripheral arterial thrombolysis has become established as a useful adjunct in the management of peripheral arterial ischaemia. Much has been learnt about indications,... (Review)
Review
BACKGROUND
Peripheral arterial thrombolysis has become established as a useful adjunct in the management of peripheral arterial ischaemia. Much has been learnt about indications, risks and benefits using this technique, although data from randomised controlled studies is not extensive. The optimal initial management of the acutely ischaemic leg needs to be determined.
OBJECTIVES
To determine if surgery or thrombolysis is the preferred option in the initial treatment of acute limb ischaemia.
SEARCH STRATEGY
The search strategy was that adopted by the Cochrane Review Group on Peripheral Vascular Diseases. Additionally, reference lists of papers resulting from this search were reviewed.
SELECTION CRITERIA
All randomised studies comparing thrombolysis and surgery in the management of acute limb ischaemia.
DATA COLLECTION AND ANALYSIS
Trial quality was assessed and data were extracted independently by all three reviewers.
MAIN RESULTS
Patients with acute lesions of less than seven days duration had a significantly increased survival at one year for patients having thrombolysis, compared to those undergoing initial surgery [84% v 58%, p=0.01; Odds ratio (95% CI) 0.28 (0.13,0.63)] largely associated with a reduced level of in-hospital cardio-pulmonary complications (Ouriel 1994). Lesions less than 14 days duration fared better with initial lysis with a reduced amputation and reduced death rate at six months [15.3% v 37.5%; p=0.001; Odds ratio (95%CI) 0.29 (0.12,0.72)] (STILE 1994), compared to initial surgery. Analysis of the same trial at one year however revealed that native vessel thromboses had a more favourable outcome with initial surgery, largely due to continuing ischaemia in the lytic group [64% v 35%; p<0.0001; Odds ratio (95%CI) 3.26(1.96,5.52)] (Weaver 1996). Bypass graft thromboses less than 14 days old treated with initial thrombolysis were shown to have a reduced amputation rate (15% v 47%; p=0.05). However, overall, one year results revealed that thrombolysis of thrombosed grafts was associated with a higher level of continued ischaemia [73% v 50%; P=0.010; Odds ratio (95%CI) 2.72(1.27,5.80)] (Comerota 1996).
REVIEWER'S CONCLUSIONS
A universal initial treatment with either surgery or thrombolysis cannot be advocated on the available evidence. There is no overall difference in limb salvage or death at one year between initial surgery and initial thrombolysis. Thrombolysis may however be associated with a higher risk of ongoing limb ischaemia, and a higher overall risk of haemorrhagic complications including stroke. The higher risk of complications needs to be balanced against the risks of surgery in the individual patient.
Topics: Humans; Ischemia; Leg; Outcome Assessment, Health Care; Randomized Controlled Trials as Topic; Thrombolytic Therapy; Time Factors
PubMed: 11034762
DOI: 10.1002/14651858.CD002784