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Cardiology Clinics Feb 2015Critical limb ischemia (CLI), the most advanced form of peripheral artery disease (PAD), carries grave implications with regard to morbidity and mortality. Within 1 year... (Review)
Review
Critical limb ischemia (CLI), the most advanced form of peripheral artery disease (PAD), carries grave implications with regard to morbidity and mortality. Within 1 year of CLI diagnosis, 40% to 50% of diabetics will experience an amputation, and 20% to 25% will die. Management is optimally directed at increasing blood flow to the affected extremity to relieve rest pain, heal ischemic ulcerations, avoid limb loss, and prevent cardiovascular events. This management is achieved by guideline-directed medical therapy and risk factor modification, whereas the mainstay of therapy remains revascularization by endovascular or surgical means for patients who are deemed potential candidates.
Topics: Aged; Cross-Sectional Studies; Female; Humans; Ischemia; Leg; Male; Middle Aged; Prognosis; Referral and Consultation; United States
PubMed: 25439329
DOI: 10.1016/j.ccl.2014.09.008 -
Journal of Vascular Surgery Jan 2016
Topics: Amputation, Surgical; Female; Hemodynamics; Humans; Ischemia; Lower Extremity; Male; Peripheral Arterial Disease
PubMed: 26412437
DOI: 10.1016/j.jvs.2015.07.102 -
Journal of Vascular Surgery Dec 2022The traditionally reported outcomes for patients with ischemic wounds have centered on amputation-free survival. However, that discounts the importance of other...
BACKGROUND
The traditionally reported outcomes for patients with ischemic wounds have centered on amputation-free survival. However, that discounts the importance of other patient-centered outcomes such as the wound healing time (WHT) and wound-free period (WFP). We evaluated the long-term wound outcomes of patients treated for chronic limb-threatening ischemia at our institution.
METHODS
From 2014 to 2017, we identified all patients with chronic limb-threatening ischemia and ischemic wounds using symptomatic and hemodynamic criteria. The primary data included the wound size, wound location, WIfI (wound, ischemia, foot infection) grade, WHT, WFP, minor and major amputation, and death. Wounds were not considered healed if the patient had required a major amputation or had died before wound healing. The WHT was calculated as the interval in days between the diagnosis and determination of a healed wound. The WFP was calculated as the interval in days between a healed wound and wound recurrence, major amputation, death, or the end of the study period. A comparison of the wound healing parameters stratified by revascularization status was performed using the Student t test. A generalized linear model adjusted for age, sex, initial wound size, and WIfI grade was used to evaluate the risk of wound healing with and without revascularization.
RESULTS
A total of 256 patients had presented with 372 wounds. Of the 256 patients, 48% had undergone revascularization. During the study period, 97 minor amputations and 100 major amputations had been required, and 132 patients had died. The average wound size was 13.9 ± 52.0 cm; however, for the 155 wounds that had healed, the average size was only 4.0 ± 9.6 cm (P = .002). No differences were found in the wound size when stratified by revascularization status (P = .727). Adjusted for the initial wound size, the risk of wound healing was not different when stratified by revascularization (risk ratio, 1.22; 95% confidence interval, 0.80-1.87; P = .354). For those whose wounds had healed, the average WHT and WFP were 173 ± 169 days and 775 ± 317 days, respectively. The WHT was not faster for the revascularized group (155 days vs 188 days; P = .221). When stratified by revascularization status, the rate of wound recurrence was 4.6 vs 8.9 wounds per 100 person-years for the revascularized and nonrevascularized groups, respectively (P = .125).
CONCLUSIONS
In our study, we found that, except for patients who presented with severe ischemia, revascularization was not associated with improved rates of wound healing. Among the wounds that healed, regardless of the initial ischemia grade, revascularization was not associated with a faster WHT or longer WFPs.
Topics: Humans; Limb Salvage; Chronic Limb-Threatening Ischemia; Treatment Outcome; Risk Factors; Time Factors; Retrospective Studies; Ischemia; Peripheral Arterial Disease
PubMed: 35810955
DOI: 10.1016/j.jvs.2022.05.025 -
Angiology Aug 2013Critical limb ischemia (CLI) is a severe form of peripheral artery disease associated with high morbidity and mortality. The primary therapeutic goals in treating CLI... (Review)
Review
Critical limb ischemia (CLI) is a severe form of peripheral artery disease associated with high morbidity and mortality. The primary therapeutic goals in treating CLI are to reduce the risk of adverse cardiovascular events, relieve ischemic pain, heal ulcers, prevent major amputation, and improve quality of life (QoL) and survival. These goals may be achieved by medical therapy, endovascular intervention, open surgery, or amputation and require a multidisciplinary approach including pain management, wound care, risk factors reduction, and treatment of comorbidities. No-option patients are potential candidates for the novel angiogenic therapies. The application of genetic, molecular, and cellular-based modalities, the so-called therapeutic angiogenesis, in the treatment of arterial obstructive diseases has not shown consistent efficacy. This article summarizes the current status related to the management of patients with CLI and discusses the current findings of the emerging modalities for therapeutic angiogenesis.
Topics: Angiogenic Proteins; Animals; Bone Marrow Transplantation; Cardiovascular Agents; Critical Illness; Endovascular Procedures; Genetic Therapy; Humans; Ischemia; Lower Extremity; Neovascularization, Physiologic; Stem Cell Transplantation; Treatment Outcome; Vascular Surgical Procedures; Wound Healing
PubMed: 23129733
DOI: 10.1177/0003319712464514 -
The Cochrane Database of Systematic... Jan 2018Peripheral arterial occlusive disease (PAOD) is a common cause of morbidity and mortality due to cardiovascular disease in the general population. Although numerous... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Peripheral arterial occlusive disease (PAOD) is a common cause of morbidity and mortality due to cardiovascular disease in the general population. Although numerous treatments have been adopted for patients at different disease stages, no option other than amputation is available for patients presenting with critical limb ischaemia (CLI) unsuitable for rescue or reconstructive intervention. In this regard, prostanoids have been proposed as a therapeutic alternative, with the aim of increasing blood supply to the limb with occluded arteries through their vasodilatory, antithrombotic, and anti-inflammatory effects. This is an update of a review first published in 2010.
OBJECTIVES
To determine the effectiveness and safety of prostanoids in patients with CLI unsuitable for rescue or reconstructive intervention.
SEARCH METHODS
For this update, the Cochrane Vascular Information Specialist searched the Specialised Register (January 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1). In addition, we searched trials registries (January 2017) and contacted pharmaceutical manufacturers, in our efforts to identify unpublished data and ongoing trials.
SELECTION CRITERIA
Randomised controlled trials describing the efficacy and safety of prostanoids compared with placebo or other pharmacological control treatments for patients presenting with CLI without chance of rescue or reconstructive intervention.
DATA COLLECTION AND ANALYSIS
Two review authors independently selected trials, assessed trials for eligibility and methodological quality, and extracted data. We resolved disagreements by consensus or by consultation with a third review author.
MAIN RESULTS
For this update, 15 additional studies fulfilled selection criteria. We included in this review 33 randomised controlled trials with 4477 participants; 21 compared different prostanoids versus placebo, seven compared prostanoids versus other agents, and five conducted head-to-head comparisons using two different prostanoids.We found low-quality evidence that suggests no clear difference in the incidence of cardiovascular mortality between patients receiving prostanoids and those given placebo (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.41 to 1.58). We found high-quality evidence showing that prostanoids have no effect on the incidence of total amputations when compared with placebo (RR 0.97, 95% CI 0.86 to 1.09). Adverse events were more frequent with prostanoids than with placebo (RR 2.11, 95% CI 1.79 to 2.50; moderate-quality evidence). The most commonly reported adverse events were headache, nausea, vomiting, diarrhoea, flushing, and hypotension. We found moderate-quality evidence showing that prostanoids reduced rest-pain (RR 1.30, 95% CI 1.06 to 1.59) and promoted ulcer healing (RR 1.24, 95% CI 1.04 to 1.48) when compared with placebo, although these small beneficial effects were diluted when we performed a sensitivity analysis that excluded studies at high risk of bias. Additionally, we found evidence of low to very low quality suggesting the effects of prostanoids versus other active agents or versus other prostanoids because studies conducting these comparisons were few and we judged them to be at high risk of bias. None of the included studies assessed quality of life.
AUTHORS' CONCLUSIONS
We found high-quality evidence showing that prostanoids have no effect on the incidence of total amputations when compared against placebo. Moderate-quality evidence showed small beneficial effects of prostanoids for rest-pain relief and ulcer healing when compared with placebo. Additionally, moderate-quality evidence showed a greater incidence of adverse effects with the use of prostanoids, and low-quality evidence suggests that prostanoids have no effect on cardiovascular mortality when compared with placebo. None of the included studies reported quality of life measurements. The balance between benefits and harms associated with use of prostanoids in patients with critical limb ischaemia with no chance of reconstructive intervention is uncertain; therefore careful assessment of therapeutic alternatives should be considered. Main reasons for downgrading the quality of evidence were high risk of attrition bias and imprecision of effect estimates.
Topics: Alprostadil; Amputation, Surgical; Epoprostenol; Humans; Iloprost; Ischemia; Leg; Leg Ulcer; Nafronyl; Nicotinic Acids; Pentoxifylline; Peripheral Vascular Diseases; Prostaglandins; Randomized Controlled Trials as Topic; Vasodilator Agents
PubMed: 29318581
DOI: 10.1002/14651858.CD006544.pub3 -
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 -
Methodist DeBakey Cardiovascular Journal 2012The evaluation of patients at risk for limb loss secondary to peripheral arterial disease begins with a complete history and physical exam, and noninvasive studies in... (Review)
Review
The evaluation of patients at risk for limb loss secondary to peripheral arterial disease begins with a complete history and physical exam, and noninvasive studies in the vascular lab, including duplex ultrasonography. However, successful revascularization depends on high-quality, accurate imaging of the lower extremity vasculature. The traditional gold standard for vascular imaging, digital subtraction angiography, has been improved upon as technologic advances have enabled high-quality alternatives for preoperative (i.e., computed tomography [CT] angiography and magnetic resonance angiography [MRA]) and intraoperative imaging (i.e., intravascular ultrasound [IVUS], cone beam CT, and CO(2) angiography). Here we describe these advanced invasive and noninvasive imaging alternatives and their utility in limb salvage procedures.
Topics: Angiography, Digital Subtraction; Diagnostic Imaging; Humans; Ischemia; Limb Salvage; Lower Extremity; Magnetic Resonance Angiography; Preoperative Care; Ultrasonography, Doppler, Duplex
PubMed: 23342185
DOI: 10.14797/mdcj-8-4-28 -
Tidsskrift For Den Norske Laegeforening... Apr 2005Arterial ischaemic ulcers develop because of inadequate perfusion leading to local ischaemia in the skin and underlying tissue. The most common cause is peripheral... (Review)
Review
Arterial ischaemic ulcers develop because of inadequate perfusion leading to local ischaemia in the skin and underlying tissue. The most common cause is peripheral arterial disease, giving rise to symptoms like intermittent claudication, rest pain and gangrene, in addition to local ulceration. Diabetes mellitus increases the risk of ulcer formation; admittedly mainly neuropathic ulcers with a low component of peripheral arterial disease. Yet a combination of neuropathy and ischaemia is common ("neuro-ischaemic ulcer"). A thorough patient history and clinical examination can help discriminate arterial ulcers from venous, pressure, traumatic and vasculitis ulcers. Reduction of ankle systolic pressure and calculated ankle/brachial index, sometimes additional other non-invasive laboratory tests, confirm peripheral arterial disease. The primary treatment of arterial ischaemic ulcer is to increase blood supply to the affected area, primarily by endovascular treatment or open arterial reconstruction. Endovascular treatment (balloon angioplasty) is the method of choice because of graft infection risk in patients with open ulcers. Most arterial ischaemic ulcers will progress to healing if the blood supply is reestablished.
Topics: Angioplasty, Balloon; Antihypertensive Agents; Arteries; Atmosphere Exposure Chambers; Blood Pressure Determination; Humans; Ischemia; Leg Ulcer; Vascular Surgical Procedures; Venous Insufficiency
PubMed: 15815738
DOI: No ID Found -
European Journal of Vascular and... Jan 2004Digital ischemia in dialysis patients due to arteriovenous fistulas (AVF) is a rare condition, occurring in 4% of patients. The etiology is different from lower limb... (Review)
Review
Digital ischemia in dialysis patients due to arteriovenous fistulas (AVF) is a rare condition, occurring in 4% of patients. The etiology is different from lower limb ischemia. Blood shunting through the AVF may cause stealing of blood and hypoperfusion in distal tissues, leading to pain, discolorisation and ulcers. High-flow AVFs have greater risk on ischemia than normal flow AVFs, however combined with peripheral arteriosclerotic disease the latter may also leads to ischemia. A non-invasive and angiographic diagnosis is of importance to determine treatment options. Augmentation of arterial inflow by interventional techniques and/or AVF bloodflow-reducing surgical procedures may eliminate pain and heal ulcers. The best results are obtained by bypassing the arteriovenous anastomotic site and interruption of steal phenomenon by ligation of the artery distal to the AV anastomosis.
Topics: Angioplasty, Balloon; Arm; Arteriovenous Shunt, Surgical; Humans; Ischemia; Renal Dialysis; Vascular Surgical Procedures
PubMed: 14652830
DOI: 10.1016/j.ejvs.2003.10.007 -
Annals of Vascular Surgery Aug 2022For many surgeons the outbreak of SARS-CoV-2 meant a downscaling of surgical interventions. The aim of this study was to investigate the impact of the measures taken on...
BACKGROUND
For many surgeons the outbreak of SARS-CoV-2 meant a downscaling of surgical interventions. The aim of this study was to investigate the impact of the measures taken on the care for patients with peripheral arterial disease (PAOD) and acute limb ischemia (ALI).
METHODS
A retrospective analysis of the vascular practices of 2 major teaching hospitals in the Netherlands was performed. All interventions and outpatient visits for PAOD or ALI in 2020 were included. Patients treated in 2018 and 2019 were to serve as a control group. Data were analysed using descriptive statistics.
RESULTS
In 2020, a total of 1513 procedures were performed for PAOD or ALI. This did not differ significantly from previous years. Overall, Fontaine 2 and 4 were the most frequent indications for intervention. A significant increase in the number of major amputations was observed in 2020 compared to 2018 (P< 0.01). This was mainly due to patients suffering from PAOD Fontaine 4. Inversely, a reduction in the number of femoro-popliteal bypasses was observed between 2020 and 2018. The number of outpatient visit due to Fontaine 2 was significantly lower in 2020 compared to 2018.
CONCLUSIONS
The vascular practices of our hospitals were minimally influenced by the measures taken due to the outbreak of SARS-CoV-2. There was an increase in the number of amputation but an enormous surge in patients presenting with critical limb ischemia was not observed.
Topics: Amputation, Surgical; Arterial Occlusive Diseases; COVID-19; Humans; Ischemia; Limb Salvage; Pandemics; Peripheral Arterial Disease; Retrospective Studies; Risk Factors; SARS-CoV-2; Treatment Outcome
PubMed: 35108551
DOI: 10.1016/j.avsg.2022.01.012