P5.01 ASSESSMENT OF THE EFFICACY OF TREATMENT OPTIONS IN CRITICAL LIMB ISCHAEMIA ACCORDING TO PATIENT-ORIENTED OUTCOMES

Patients with critical limb ischaemia (CLI) constitute a subgroup of patients with particularly severe peripheral arterial occlusive disease (PAD). Treatment modalities for these patients that often exhibit multilevel lesions and severe vascular calcifications are complicated due to multiple comorbidities, i.e. of cardiac and vascular but also of renal origin. These need to be taken into consideration while planning treatment options. Although CLI is associated with considerably high morbidity and mortality rates, the clinical outcome of patients being subjected to revascularisation has improved substantially in recent years. This is mainly due to improved secondary prevention strategies as well as dedicated endovascular innovations for this most challenging patient cohort. The aim of this article is to provide a discussion of the contemporary treatment concepts for CLI patients with a focus on arterial revascularisation.

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Incidence, predictors, and treatment options of critical limb ischaemia after use of collagen plug-based vascular closure devices

EuroIntervention ◽

10.4244/eijv11i7a166 ◽

2015 ◽

Vol 11 (8) ◽

pp. 816-823 ◽

Cited By ~ 1

Author(s):

Omran Amer ◽

Siri Binger ◽

Steffen Desch ◽

Hans Michael Harnoss ◽

Gerhard Schuler ◽

...

Keyword(s):

Treatment Options ◽

Critical Limb Ischaemia ◽

Limb Ischaemia ◽

Vascular Closure Devices

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Maggot debridement therapy in critical limb ischaemia: a case study

Journal of Wound Care ◽

10.12968/jowc.2020.29.sup12.s28 ◽

2020 ◽

Vol 29 (Sup12) ◽

pp. S28-S32

Author(s):

Taku Maeda ◽

Yuhei Yamamoto ◽

Naoki Murao ◽

Toshihiko Hayashi ◽

Chu Kimura ◽

...

Keyword(s):

Wound Care ◽

Treatment Options ◽

Critical Limb Ischaemia ◽

Limb Ischaemia ◽

Necrotic Tissue ◽

Necrotic Bone ◽

Maggot Debridement Therapy ◽

First Line Therapy ◽

Before And After ◽

Skin Perfusion Pressure

Objective: In critical limb ischaemia (CLI), first-line therapy is revascularisation, but alternative treatment options are needed in certain cases. Maggot debridement therapy (MDT) is historically considered to be contraindicated in ischaemic ulcers. Wound care in patients with CLI is becoming increasingly diverse with the development of novel revascularisation strategies; therefore, CLI now needs to be reconsidered as an indication for MDT. Method: We retrospectively reviewed five legs with CLI (five male, one female) treated with MDT between January 2013 and December 2017. Changes in skin perfusion pressure (SPP) around the ulcer before and after MDT were evaluated. One or two cycles of MDT were performed (eight in total). We also evaluated the proportion of necrotic tissue in the ulcer and the presence of exposed necrotic bone. The proportion of necrotic tissue in the ulcer was classified as NT 1+ (<25%), NT 2+ (25–50%), NT 3+ (50–75%) or NT 4+ (>75%). Results: When the proportion of necrotic tissue was >50%, with no exposed necrotic bone in the wound, an increase in SPP was observed after five (62.5%) of eight cycles of MDT. And with a proportion of necrotic tissue of <25% and/or exposed necrotic bone in the wound, a decrease in SPP was observed after three (37.5%) of eight cycles. Wound healing was accelerated in the presence of increased SPP. Conclusion: Effective MDT with increased SPP requires an ulcerative state of necrotic tissue grade > NT 3+, with no exposed necrotic bone.

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BEST Endovascular Versus Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) Trial

Vascular and Endovascular Review ◽

10.15420/ver.2019.12 ◽

2020 ◽

Vol 3 ◽

Author(s):

Raghu Motaganahalli ◽

Matthew Menard ◽

Matt Koopman ◽

Alik Farber

Keyword(s):

Surgical Therapy ◽

Critical Limb Ischemia ◽

Controlled Trial ◽

Treatment Options ◽

Limb Ischemia ◽

Critical Limb Ischaemia ◽

Limb Ischaemia ◽

Open Label ◽

Appropriate Therapy ◽

Randomised Controlled

The Best Endovascular versus Best Surgical Therapy in Patients with Critical Limb Ischemia trial (BEST-CLI) is an international, prospective, multicentre, multidisciplinary and pragmatic, open-label, superiority-based, comparative-effectiveness randomised controlled trial designed to address the knowledge gap in choosing the appropriate therapy for the treatment of critical limb ischaemia (CLI). This study compares the effectiveness of the best available surgical treatment with the best available endovascular treatment in adults with CLI who are eligible for both treatment options. The study has completed its enrolment phase and patients included in the study are currently being followed up to 50 months. Results of the study promise to provide us with answers to several questions regarding treatment options for patients with CLI, more recently referred to as chronic limb-threatening ischaemia.

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Chronic limb ischaemia

Current Surgical Guidelines ◽

10.1093/med/9780198794769.003.0046 ◽

2018 ◽

pp. 443-452

Author(s):

Abdullah Jibawi ◽

Mohamed Baguneid ◽

Arnab Bhowmick

Keyword(s):

Lower Limb ◽

Treatment Options ◽

Arterial Disease ◽

Critical Limb Ischaemia ◽

Limb Ischaemia ◽

Common Condition ◽

Risk Factor Modification ◽

Non Invasive ◽

Peripheral Arterial ◽

Factor Modification

Chronic limb ischaemia or peripheral arterial disease is a common condition that is caused by the build-up of atheroma. This chapter examines the risk factors for developing this condition and describes non-invasive and invasive diagnostic investigations. The management of this condition depends on the severity of the presentation. Intermittent claudication is largely managed conservatively with risk factor modification and lifestyle adjustment unless walking limitation is severe. Critical limb ischaemia is treated in a more aggressive fashion by an endovascular or surgical approach. This chapter examines how the Transatlantic Society Consensus (TASC) relates to the optimum treatment options for occlusive disease in the lower limb.

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Critical limb ischaemia in diabetes: definition, assessment, prognosis

VASA ◽

10.1024/0301-1526.30.s58.21 ◽

2001 ◽

Vol 30 (Supplement 58) ◽

pp. 21-27

Author(s):

Luther

Keyword(s):

Diabetic Foot ◽

Laboratory Tests ◽

Critical Limb Ischaemia ◽

Limb Ischaemia ◽

Clinical Use ◽

Arterial Reconstruction ◽

Arterial Circulation ◽

Diabetic Foot Disease ◽

Foot Disease ◽

Fontaine Classification

In diabetic foot disease, critical limb ischaemia (CLI) cannot be precisely described using established definitions. For clinical use, the Fontaine classification complemented with any objective verification of a reduced arterial circulation is sufficient for decision making. For scientific purposes, objective measurement criteria should be reported. Assessment of CLI should rely on the physical examination of the limb arteries, complemented by laboratory tests like the shape of the PVR curve at ankle or toe levels, and arteriography. The prognosis of CLI in diabetic foot disease depends on the success of arterial reconstruction. The best prognosis for the patients is with a preserved limb. Reconstructive surgery is the best choice for the majority of patients.

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Comparison of one-year prognosis of patients classified as chronic critical lower limb ischaemia according to TASC II or European consensus definition in the COPART cohort

VASA ◽

10.1024/0301-1526/a000432 ◽

2015 ◽

Vol 44 (3) ◽

pp. 0220-0228 ◽

Cited By ~ 4

Author(s):

Marion Vircoulon ◽

Carine Boulon ◽

Ileana Desormais ◽

Philippe Lacroix ◽

Victor Aboyans ◽

...

Keyword(s):

Medical Treatment ◽

Critical Limb Ischaemia ◽

Limb Ischaemia ◽

Medical Group ◽

Consensus Definition ◽

Transcutaneous Oxygen ◽

European Consensus ◽

Group A ◽

One Year ◽

Group B

Background: We compared one-year amputation and survival rates in patients fulfilling 1991 European consensus critical limb ischaemia (CLI) definition to those clas, sified as CLI by TASC II but not European consensus (EC) definition. Patients and methods: Patients were selected from the COPART cohort of hospitalized patients with peripheral occlusive arterial disease suffering from lower extremity rest pain or ulcer and who completed one-year follow-up. Ankle and toe systolic pressures and transcutaneous oxygen pressure were measured. The patients were classified into two groups: those who could benefit from revascularization and those who could not (medical group). Within these groups, patients were separated into those who had CLI according to the European consensus definition (EC + TASC II: group A if revascularization, group C if medical treatment) and those who had no CLI by the European definition but who had CLI according to the TASC II definition (TASC: group B if revascularization and D if medical treatment). Results: 471 patients were included in the study (236 in the surgical group, 235 in the medical group). There was no difference according to the CLI definition for survival or cardiovascular event-free survival. However, major amputations were more frequent in group A than in group B (25 vs 12 %, p = 0.046) and in group C than in group D (38 vs 20 %, p = 0.004). Conclusions: Major amputation is twice as frequent in patients with CLI according to the historical European consensus definition than in those classified to the TASC II definition but not the EC. Caution is required when comparing results of recent series to historical controls. The TASC II definition of CLI is too wide to compare patients from clinical trials so we suggest separating these patients into two different stages: permanent (TASC II but not EC definition) and critical ischaemia (TASC II and EC definition).

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Vascular trauma of the hand – a systematic review

VASA ◽

10.1024/0301-1526/a000743 ◽

2019 ◽

Vol 48 (3) ◽

pp. 205-215 ◽

Cited By ~ 1

Author(s):

Uwe Wahl ◽

Ingmar Kaden ◽

Andreas Köhler ◽

Tobias Hirsch

Keyword(s):

Duplex Sonography ◽

Vascular Trauma ◽

Vascular Lesions ◽

Critical Limb Ischaemia ◽

Limb Ischaemia ◽

Limited Information ◽

Endovascular Interventions ◽

Provocation Tests ◽

Objective Basis ◽

Allen Test

Abstract. Hypothenar or thenar hammer syndrome (HHS) and hand-arm vibration syndrome (HAVS) are diseases caused by acute or chronic trauma to the upper extremities. Since both diseases are generally related to occupation and are recognised as occupational diseases in most countries, vascular physicians need to be able to distinguish between the two entities and differentiate them from other diagnoses. A total of 867 articles were identified as part of an Internet search on PubMed and in non-listed occupational journals. For the analysis we included 119 entries on HHS as well as 101 papers on HAVS. A professional history and a job analysis were key components when surveying the patient’s medical history. The Doppler-Allen test, duplex sonography and optical acral pulse oscillometry were suitable for finding an objective basis for the clinical tests. In the case of HHS, digital subtraction angiography was used to confirm the diagnosis and plan treatment. Radiological tomographic techniques provided very limited information distal to the wrist. The vascular component of HAVS proved to be strongly dependent on temperature and had to be differentiated from the various other causes of secondary Raynaud’s phenomenon. The disease was medicated with anticoagulants and vasoactive substances. If these were not effective, a bypass was performed in addition to various endovascular interventions, especially in the case of HHS. Despite the relatively large number of people exposed, trauma-induced circulatory disorders of the hands can be observed in a comparatively small number of cases. For the diagnosis of HHS, the morphological detection of vascular lesions through imaging is essential since the disorder can be accompanied by critical limb ischaemia, which may require bypass surgery. In the case of HAVS, vascular and sensoneurological pathologies must be objectified through provocation tests. The main therapeutic approach to HAVS is preventing exposure.

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