Wound healing and functional outcomes after infrainguinal bypass with reversed saphenous vein for critical limb ischemia

Purpose: Critical limb ischemia (CLI) is an entity with high mortality if not properly treated. The primary aim of CLI revascularization is to enhance wound healing, which greatly depends on microvascular circulation. The available tools for assessment of revascularization success are deficient in the evaluation of local microvascular tissue perfusion, that wound blush (WB) reflects. A reliable technique that assesses capillary flow to foot lesions is needed. This study aims to assess WB angiographically at sites of interest in the foot after revascularization and its impact on limb salvage in CLI. Materials and Methods: 198 CLI patients (Rutherford category 5/6) with infrainguinal atherosclerotic lesions amenable for endovascular revascularization (EVR) were included. Limbs were directly or indirectly revascularized by EVR. Direct revascularization meant that successful revascularization of the area of interest according to the angiosome concept was achieved. A completion angiographic run was taken to assess WB. Patients were divided into 2 groups; positive and negative WB groups. In the event of a disagreement between the observational investigators, the digital subtraction angiography (DSA) series was analyzed for hemodynamic changes with a computerized 2D color-coded DSA (Syngo iFlow). Results: 176 limbs had successful revascularization in 157 patients. The successful revascularization rate was 88.9% (176/198), with technical failure encountered in 22 limbs. 121 patients had positive WB and 55 patients had negative WB. Direct revascularization of target areas was obtained in 98 limbs (55.7%). There was a significant difference in the rate of achieving direct flow to the lesion between the positive WB and negative WB groups (36.4% vs 19.3%, p≤0.001). We noticed a nonsignificant difference between patients who had direct revascularization of the foot lesion(s) and those who had indirect revascularization as regards limb salvage. Patients were followed up for 25.2 ± 12.7 months. By the end of the first year, limb salvage rate was significantly higher in patients who had positive WB (98% vs 63%, p<0.001, after 2 years (97% vs 58%, p<0.001) and after 3 years (94% vs 51.5%, p<0.001). Conclusions: WB is an important predictor and a prognostic factor for wound healing in CLI patients with soft tissue lesions.

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LEA 13. Safety and Effectiveness of a New Valvulotome: Insights From the LIMBSAVE Registry (treatment of critical Limb IscheMia with infragenicular Bypass adopting in situ SAphenous VEin technique)

Journal of Vascular Surgery ◽

10.1016/j.jvs.2019.08.030 ◽

2019 ◽

Vol 70 (5) ◽

pp. e120

Author(s):

Nicola Troisi

Keyword(s):

Critical Limb Ischemia ◽

Saphenous Vein ◽

Limb Ischemia

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Abstract 14293: Time to Wound Healing and Major Adverse Limb Events in Patients With Critical Limb Ischemia Treated With Endovascular Therapy

Circulation ◽

10.1161/circ.132.suppl_3.14293 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Grant W Reed ◽

Negar Salehi ◽

Pejman Raeisi-Giglou ◽

Umair Malik ◽

Rami Kafa ◽

...

Keyword(s):

Wound Healing ◽

Endovascular Therapy ◽

Critical Limb Ischemia ◽

Proportional Hazards ◽

Limb Ischemia ◽

Major Amputation ◽

Cox Proportional Hazards ◽

Time Dependent ◽

Kaplan Meier

Introduction: There have been few studies evaluating the influence of time to wound healing on outcomes in patients with critical limb ischemia (CLI) after endovascular therapy. Methods: In this prospective study, patients with CLI treated with endovascular therapy were assessed for comorbidities, presence of wounds, wound healing, and major adverse limb events (MALE; major amputation, surgical endartectomy, or bypass) over time. The incidence of MALE was compared across patient and wound characteristics by Kaplan-Meier analysis. Associations between these variables and MALE were determined by Cox proportional hazards analysis. Results: A total of 252 consecutive patients with CLI were treated between November 1, 2011 and April 1, 2015; 179 (71%) had wounds, of which 97 (54%) healed. During median follow-up of 12.7 months (interquartile range 3.9 - 23.9 months), 46 (18%) had MALE. Wounds were associated with a greater risk of MALE (Hazard Ratio [HR] 3.5; 95% Confidence Interval [CI] 1.4-8.9; p=0.008). As a time-dependent covariate, wound healing was associated with less MALE (HR 0.23; 95% CI 0.10-0.53; p<0.001), and MALE was more frequent in patients with unhealed wounds (23% vs 11%; p<0.0001) (Figure - A). There was significantly less MALE in patients whose wounds healed within 4 months (24% vs 10%; p=0.032) (Figure - B), and less major amputation in those with healed wounds within 3 months (16% vs 5%; p=0.033). After multivariate adjustment for age, presence of diabetes, renal function, wound size, and procedural failure, independent predictors of MALE were wound healing as a time-dependent covariate (HR 0.18; 95% CI 0.08 - 0.40; p<0.0001), and creatinine ≥ 2 (HR 2.3; 95% CI 1.3-4.2; p=0.005). Conclusions: A shorter time to wound healing is associated with less MALE in patients with CLI after endovascular therapy. Efforts should be made to achieve wound healing as quickly as possible in this population, especially in those with renal dysfunction.

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Rest Pain and Wound Healing in Patients Suffering Critical Limb Ischemia (CLI) Benefits from Recombinant Growth Hormone (RGH) Therapy: The First-in-man Pilot Study for the use of RGH in CLI

European Journal of Vascular and Endovascular Surgery ◽

10.1016/j.ejvs.2019.06.983 ◽

2019 ◽

Vol 58 (6) ◽

pp. e356-e357

Author(s):

Diego C. Valdes ◽

Santiago P. Cachafeiro ◽

Clara Á. Villamarín ◽

Julia R. Fernández ◽

Rodrigo F. González ◽

...

Keyword(s):

Growth Hormone ◽

Wound Healing ◽

Pilot Study ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Rest Pain ◽

Recombinant Growth Hormone

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Real-Time Quantitative Measurements of Foot Perfusion in Patients With Critical Limb Ischemia

Vascular and Endovascular Surgery ◽

10.1177/1538574419833223 ◽

2019 ◽

Vol 53 (4) ◽

pp. 310-315 ◽

Cited By ~ 3

Author(s):

O. Mironov ◽

R. Zener ◽

N. Eisenberg ◽

K.T. Tan ◽

Graham Roche-Nagle

Keyword(s):

Wound Healing ◽

Real Time ◽

Critical Limb Ischemia ◽

Ankle Brachial Index ◽

Microvascular Disease ◽

Limb Ischemia ◽

Major Amputation ◽

Rest Pain ◽

Quantitative Measurements ◽

Patients Experience

Introduction: Current methods of evaluating adequacy of endovascular procedures are imperfect and do not always predict which patients will do well. The purpose of this study was to evaluate the role of real-time quantitative measurements of perfusion among patients with critical limb ischemia. Materials and Methods: Thirty-four patients with critical limb ischemia undergoing endovascular treatment were recruited. Perfusion Images of the foot were obtained pre and post successful angioplasty using an SPY Elite System (Novadaq Technologies, Ontario, Canada). Patients were followed for 6 months. Subsequently a logistic regression was performed to determine whether intraprocedural perfusion parameters predicted the odds of wound healing. Results: Twenty-nine patients had successful angioplasty. Median age was 69.5% ± 8.3; 75% were men and 64% were diabetic. Rutherford stages were (4%-39%, 5%-57%, 6%-4%), and the average target limb ankle–brachial index (ABI) was 0.58 (SD 2.24). There was no significant correlation between the ABI and perfusion parameters. Inflow perfusion rate correlated significantly with Rutherford stage (Spearman rho 0.398, P = .036). After successful angioplasty 39% had a decrease in inflow rate and 57% had a decreased total inflow. In all, 25 patients completed 6 months of follow-up. Resolution of rest pain and/or healing of the ischemic wound occurred in 10 (40%) patients at 1 month, 4 (16%) at 3 months, and 2 (8%) at 6 months. One patient underwent a major amputation at 2 months. Eight (32%) patients never healed or had persistent rest pain. None of the real-time perfusion variables were significant predictors of wound healing. Conclusion: Many patients experience a paradoxical decrease in perfusion following successful angioplasty suggesting perfusion may not correlate with angiographic outcome, possibly due to microemboli, microvascular disease, or vasospasm. Real-time perfusion imaging following intra-arterial infusion of indocyanine green does not predict the odds of wound healing.

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