Patients with Critical Limb Ischemia Requiring Intervention: Occurrence and Risk Factors for Reintervention

Objectives Inflammation is a component in the pathogenesis of critical limb ischemia. We aimed to assess how inflammation affects response to treatment in patients treated for critical limb ischemia using neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocytes ratios (PLR) as markers of inflammation. Methods Patients in a single tertiary cardiovascular center with critical limb ischemia unsuitable for surgical or interventional revascularization were retrospectively identified. Data were collected on medical history for risk factors, previous surgical or endovascular revascularization, and outcome. A standard regimen of low molecular weight heparin, aspirin, statins, iloprost infusions, and a standard pain medication protocol were applied to each patient per hospital protocol. Patients with improvement in ischemic pain and healed ulcers made up the responders group and cases with no worsening pain or ulcer size or progression to minor or major amputations made up the non-responders group. Responders and Non-responders were compared for risk factors including pretreatment NLR and PLR. Results 268 included patients who were not candidates for surgical or endovascular revascularization were identified. Responders had significantly lower pretreatment NLR (4.48 vs 8.47, p < 0.001) and PLR (162.19 vs 225.43, p = 0.001) values. After controlling for associated risk factors NLR ≥ 4.63 (p < 0.001) and PLR ≥ 151.24 (p = 0.016) were independently associated with no response to treatment. Conclusions Neutrophil-to-lymphocyte ratio and platelet-to-lymphocytes ratio are markers of inflammation that are reduced in patients improving with medical treatment suggesting a decreased state of inflammation before treatment in responding patients.

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Isolated femoral artery revascularisation with or without iliac inflow improvement – a less invasive surgical option in critical limb ischemia

VASA ◽

10.1024/0301-1526/a000934 ◽

2021 ◽

pp. 1-7

Author(s):

Andreas S. Peters ◽

Katrin Meisenbacher ◽

Dorothea Weber ◽

Theodosios Bisdas ◽

Giovanni Torsello ◽

...

Keyword(s):

Risk Factors ◽

Femoral Artery ◽

Critical Limb Ischemia ◽

Negative Impact ◽

Limb Ischemia ◽

Major Amputation ◽

Lesion Length ◽

Vascular Intervention ◽

Selection Of Variables ◽

Surgical Option

Summary: Background: Isolated femoral artery revascularisation (iFAR) represents a well-established surgical method in the treatment of peripheral arterial disease (PAD) involving common femoral artery disease. Data for iFAR in multilevel PAD are inconsistent, particularly in patients with critical limb ischemia (CLI). The aim of the study was to evaluate the outcome of iFAR in CLI regarding major amputation and reintervention and to identify associated risk factors for this outcome. Patients and methods: The data used have been derived from the German Registry of Firstline Treatment in Critical Limb Ischemia (CRITISCH). A total of 1200 patients were enrolled in 27 vascular centres. This sub-analysis included patients, which were treated with iFAR with/without concomitant iliac intervention. For detection of risk factors for the combined endpoint of major amputation and/or reintervention, selection of variables for multiple regression was conducted using stepwise forward/backward selection by Akaike’s information criterion. Results: 95 patients were included (mean age: 72 years ± 10.82; 64.2% male). Of those, 32 (33.7%) participants reached the combined endpoint. Risk factor analysis revealed continued tobacco use (odds ratio [OR] 2.316, confidence interval [CI] 0.832–6.674), TASC D-lesion (OR: 2.293, CI: 0.869–6.261) and previous vascular intervention in the trial leg (OR: 2.720, CI: 1.037–7.381) to be associated with reaching the combined endpoint. Conclusions: iFAR provides a reasonable, surgical option to treat CLI. Lesion length (TASC D) seems to have a negative impact on outcome. Further research is required to better define the future role of iFAR for combined femoro-popliteal lesions in CLI – best in terms of a randomised controlled trial.

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Gender-related differences in critical limb ischemia due to peripheral arterial occlusive disease

Jornal Vascular Brasileiro ◽

10.1590/jvb.2013.053 ◽

2013 ◽

Vol 12 (4) ◽

pp. 278-283 ◽

Cited By ~ 1

Author(s):

Vanessa Prado dos Santos ◽

Carlos Alberto Silveira Alves ◽

Cicero Fidelis Lopes ◽

Jose Siqueira de Araujo Filho

Keyword(s):

Risk Factors ◽

Critical Limb Ischemia ◽

Peripheral Arterial Occlusive Disease ◽

Clinical Characteristics ◽

Limb Ischemia ◽

Arterial Occlusive Disease ◽

Occlusive Disease ◽

Male And Female ◽

Female Patients ◽

Peripheral Arterial

BACKGROUND: Mortality from cardiovascular disease has declined among men and increased among North American women. Recent studies have revealed differences between genders in the epidemiology of atherosclerotic disease. OBJECTIVE: To study possible differences between male and female patients with critical limb ischemia (CLI) according to risk factors of atherosclerosis and clinical characteristics of lower limbs with peripheral arterial occlusive disease (PAOD). METHODS: The study included 171 male and female patients treated for CLI due to infrainguinal PAOD and compared clinical characteristics (Rutherford category and PAOD territory), risk factors for atherosclerosis (diabetes, age, smoking and hypertension) and number of opacified arteries on digital angiograms of the leg. The EPI-INFO software was used for statistical analysis, and the level of significance was set at p<0.05. RESULTS: Mean age was 70 years, and 88 patients were men (52%). For most patients (both genders), Rutherford category was 5 (82 % of men and 70% of women; p=0.16). The group of women had higher mean age (73 vs. 67 years; p=0.0002) and greater prevalence of diabetes (66% vs. 45%; p=0.003) and hypertension (90% vs. 56%; p=0.0000001). Among men, the prevalence of smoking was higher (76% vs. 53%; p=0.0008). The analysis of digital angiograms revealed that opacification of only one artery in the leg was found for 74% of women (vs. 50% of men). CONCLUSION: The prevalence of risk factors for atherosclerosis and the characteristics of PAOD are different between male and female patients with CLI.

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Risk Factors for Amputation After Revascularisation for Critical Limb Ischemia – A Competing Risk Analysis of a Population Based Cohort.

European Journal of Vascular and Endovascular Surgery ◽

10.1016/j.ejvs.2019.06.1135 ◽

2019 ◽

Vol 58 (6) ◽

pp. e467-e468

Author(s):

Eva Torbjörnsson ◽

Lena Blomgren ◽

Carin Ottosson ◽

Ann-Mari Fagerdahl ◽

Lennart Boström ◽

...

Keyword(s):

Risk Factors ◽

Risk Analysis ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Population Based ◽

Competing Risk ◽

Competing Risk Analysis

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The Role of Delirium and Other Risk Factors on Mortality in Elderly Patients with Critical Limb Ischemia Undergoing Major Lower Limb Amputation

Annals of Vascular Surgery ◽

10.1016/j.avsg.2019.02.014 ◽

2019 ◽

Vol 60 ◽

pp. 270-278.e2

Author(s):

J.P. Roijers ◽

C.J. Hopmans ◽

T.L. Janssen ◽

P.G.H. Mulder ◽

M.G. Buimer ◽

...

Keyword(s):

Risk Factors ◽

Elderly Patients ◽

Critical Limb Ischemia ◽

Lower Limb ◽

Limb Ischemia ◽

Lower Limb Amputation ◽

Limb Amputation

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Prognostic factor of the two-year mortality after revascularization in patients with critical limb ischemia

Vascular ◽

10.1177/1708538116651216 ◽

2016 ◽

Vol 25 (2) ◽

pp. 123-129 ◽

Cited By ~ 4

Author(s):

Koichi Morisaki ◽

Takuya Matsumoto ◽

Yutaka Matsubara ◽

Kentaro Inoue ◽

Yukihiko Aoyagi ◽

...

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Ejection Fraction ◽

Serum Albumin ◽

Critical Limb Ischemia ◽

Serum Albumin Level ◽

Limb Ischemia ◽

Albumin Level ◽

Surgical Revascularization ◽

Hybrid Therapy

Purposes The aim of this study was to evaluate the risk factors for the two-year survival after revascularization of critical limb ischemia. Methods Between 2008 and 2012, 142 patients underwent revascularization. A retrospective analysis was performed to measure the risk factor. Results A total 85 patients underwent surgical revascularization, 31 patients underwent endovascular therapy while 26 patients underwent hybrid therapy. By multivariate analysis, the following variables were considered to be risk factors: ejection fraction <50 % (HR, 3.14; 95% CI, 1.22–7.95; P = 0.02), serum albumin level <2.5 g/dL (HR, 3.45; 95% CI, 1.01–11.7; P = 0.04) and nonambulatory status (HR, 4.11; 95% CI, 1.79–9.70; P < 0.01). The two-year survival rate of the patients with no risk factors was 85.5%, while the patients with at least one risk factor had an unfavorable prognosis (one; 56.7%, two; 45.4%). Conclusions The nonambulatory status, serum albumin level <2.5 g/dL and ejection fraction <50% were the risk factors for the two-year mortality after revascularization in critical limb ischemia patients. These risk factors may be useful for the treatment strategy of critical limb ischemia patients.

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Critical Limb Ischemia: A Practical Up-To-Date Review

Angiology ◽

10.1177/0003319717739387 ◽

2017 ◽

Vol 69 (6) ◽

pp. 465-474 ◽

Cited By ~ 8

Author(s):

Iacopo Fabiani ◽

Enrico Calogero ◽

Nicola Riccardo Pugliese ◽

Rossella Di Stefano ◽

Irene Nicastro ◽

...

Keyword(s):

Risk Factors ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Cardiovascular Complications ◽

Therapeutic Strategies ◽

Local Infection ◽

Significant Morbidity ◽

Peripheral Artery ◽

Prognostic Stratification ◽

Artery Disease

Critical limb ischemia (CLI) is the most advanced form of peripheral artery disease. It is associated with significant morbidity and mortality and high management costs. It carries a high risk of amputation and local infection. Moreover, cardiovascular complications remain a major concern. Although it is a well-known entity and new technological and therapeutic advances have been made, this condition remains poorly addressed, with significantly heterogeneous management, especially in nonexperienced centers. This review, from a third-level dedicated inpatient and outpatient cardioangiology structure, aims to provide an updated summary on the topic of CLI of its complexity, encompassing epidemiological, social, economical and, in particular, diagnostic/imaging issues, together with potential therapeutic strategies (medical, endovascular, and surgical), including the evaluation of cardiovascular risk factors, the diagnosis, and treatment together with prognostic stratification.

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Risk factors for amputation are influenced by competing risk of death in patients with critical limb ischemia

Journal of Vascular Surgery ◽

10.1016/j.jvs.2019.07.074 ◽

2020 ◽

Vol 71 (4) ◽

pp. 1305-1314.e5 ◽

Cited By ~ 1

Author(s):

Eva Torbjörnsson ◽

Lena Blomgren ◽

Ann-Mari Fagerdahl ◽

Lennart Boström ◽

Carin Ottosson ◽

...

Keyword(s):

Risk Factors ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Competing Risk ◽

Risk Of Death

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Circulating MicroRNA-4739 May Be a Potential Biomarker of Critical Limb Ischemia in Patients with Diabetes

BioMed Research International ◽

10.1155/2018/4232794 ◽

2018 ◽

Vol 2018 ◽

pp. 1-8 ◽

Cited By ~ 5

Author(s):

Ju-yi Li ◽

Biao Cheng ◽

Xiu-fang Wang ◽

Zhong-jing Wang ◽

Hong-mei Zhang ◽

...

Keyword(s):

Risk Factors ◽

Critical Limb Ischemia ◽

Area Under The Curve ◽

Limb Ischemia ◽

Circulating Microrna ◽

Roc Curve Analysis ◽

Altered Expression ◽

Potential Biomarker ◽

Patients With Diabetes ◽

Noninvasive Biomarkers

Critical limb ischemia (CLI) is the most severe manifestation of peripheral artery disease, which is common but rarely diagnosed. Noninvasive biomarkers are urgently required to assist in the diagnosis of CLI. Accumulating evidence indicates that miRNAs play an important role in the development of various diseases. In this study, microarray profiling revealed 11 miRNAs with significantly altered expression in four T2DM patients with CLI compared with that in four sex- and age-matched T2DM patients without CLI. In independent cohorts, qRT-PCR validation confirmed the increased miRNA-4739 level in patients with CLI versus patients without CLI. miRNA-4739 levels increased with FPG and HbA1c (all P < 0.05). After adjusting for the risk factors, miRNA-4739 levels were found to be associated with an increased odds ratio (OR) of T2DM with CLI (OR =12.818, 95% confidence intervals (CI) 1.148 to 143.143, P = 0.038). ROC curve analysis revealed that the area under the curve (AUC) of miR-4739+confounding risk factors was 0.94 (95% CI 0.891 to 0.998, P < 0.001), which was higher than that of confounding risk factors (AUC 0.94 vs. 0.91, 95% CI -0.122 to 0.060, P > 0.05) and of miR-4739 (AUC 0.94 vs. 0.69, 95% CI -0.399 to -0.101, P < 0.001), respectively. We conclude that elevated plasma miRNA-4739 levels are independently associated with CLI in T2DM patients. miRNA-4739 is implicated as a novel diagnostic marker and a potential therapeutic target for CLI in diabetes.

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