High and immeasurable ankle-brachial index as predictor of poor amputation-free survival in critical limb ischemia

Background: Patients with Critical Limb Ischemia (CLI) have a high risk of amputations and mortality. We hypothesize that inflammation is involved in atherosclerotic disease progression. In this study we investigate whether levels of plasma cytokines are associated with disease progression in CLI. Methods: Data were collected from a randomized controlled trial cohort investigating cell therapy for CLI (the JUVENTAS study) from 2006 to 2012. The primary outcome measures were major amputation and mortality at 6 months; secondary outcomes included Ankle/Brachial Index (ABI) and Transcutaneous O2 Pressure. Plasma was collected at inclusion in the study and a panel of cytokines consisting of GROa, HGF, LIF, SCF, SCGFb, SDF1a, TRAIL, IL-6, IL-8, FGFb, GCSF, GMCSF, IP10, MCP1, PDGFbb, RANTES, TNFa and VEGF was measured and evaluated for predictive power. Results: Data on 108 patients was collected with a follow-up of 6 months. Patients who underwent a major outcome had significantly higher levels of IL-6, IL-8 and GROa (p=0.0004, 0.006 and 0.009 resp.). Univariate Kaplan-Meier analysis showed that amputation-free survival was 94.4% in the lowest tertile, 74% in the middle tertile and 64% in the highest tertile of plasma IL-6 levels (p=0.009, Fig A). Adjustment for potential confounders in multivariate Cox proportional hazards models showed that IL-6 remained independent predictor of major outcome. The ROC of a model using Il-6 as single predictor for major outcomes is 0.73 (Fig. B) Conclusion: Plasma levels of inflammatory cytokines, in particular IL-6 are associated with disease progression in CLI and can serve as an independent predictor of amputation-free survival.

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Early outcomes of novel Temren atherectomy device combined with drug-coated balloon angioplasty for treatment of femoropopliteal lesions

Vascular ◽

10.1177/17085381211029819 ◽

2021 ◽

pp. 170853812110298

Author(s):

Görkem Yiğit

Keyword(s):

Critical Limb Ischemia ◽

Bypass Graft ◽

Ankle Brachial Index ◽

Limb Ischemia ◽

Rotational Atherectomy ◽

Total Occlusion ◽

The Mean ◽

Knee Pathology ◽

Drug Coated Balloon

Objectives In this study, perioperative properties and early outcomes of patients who underwent combined Temren rotational atherectomy (RA) and drug-coated balloon (DCB) angioplasty treatment for complex femoropopliteal lesions in a single center were reported. Methods Between June 2019 and February 2020, 40 patients who underwent combined Temren RA and DCB treatment due to critical lower limb ischemia or claudication-limiting daily living activities were retrospectively evaluated. Results The mean age of patients was 73.2 ± 7.8 years and the majority of the patients were male (65%). Of the patients, 17 had critical limb ischemia and 23 had lifestyle-limiting claudication. Pathologies were total occlusion in 33 limbs and critical stenosis in seven limbs. Nine patients previously underwent endovascular intervention or surgery. The mean total occlusion length was 140.9 ± 100.9 (range, 20–360) mm in patients with chronic total occlusion. There was an additional iliac artery pathology in 5 and below the knee pathology in 8 patients. Rotational atherectomy was possible in all cases. Flow-limiting dissection was seen in six patients (15%). Provisional stent was performed to these patients. Following Temren RA, all patients underwent DCB. Adequate vascular lumen (less than 30% stenosis) was provided in all patients and the symptoms regressed. No distal embolization was encountered. Access site complications (17.5%) were small hematoma in four patients, ecchymosis in two patients, and pseudoaneurysm of the femoral artery in one patient. The mean follow-up was 13.55 ± 4.2 (range, 1–18) months. Re-occlusion was seen in three patients (7.5%) ( n = 2 at 2 months and n = 1 at 4 months). Of these patients, two had required open revascularization via femoropopliteal bypass graft with common, superficial femoral, and popliteal artery endarterectomy and one had required femoro-posterior tibial artery bypass. Four minor toe amputations (10%) were performed to reach complete wound healing in the critical limb ischemia patients. A below-knee amputation was performed in a 94-year-old patient with long segment stenosis at the end of a 1-month follow-up period. There was no mortality after follow-ups. The Kaplan–Meier estimator estimated the rate of freedom from target lesion revascularization (TLR) which was 92.3%. The decrease in the Rutherford levels after the procedure was found to be statistically significant in 36 patients ( p < 0.001). The increase in the ankle–brachial index after the procedure was found to be statistically significant in 36 patients ( p < 0.001). Conclusions Combined use of Temren RA with adjunctive DCB is safe and effective method with high rates of primary patency and freedom from TLR and low rates of complication in the treatment of femoropopliteal lesions.

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Multidisciplinary Care Improves Amputation-Free Survival in Patients with Chronic Critical Limb Ischemia 1

50 Landmark Papers Every Vascular and Endovascular Surgeon Should Know ◽

10.1201/9780429434020-41 ◽

2020 ◽

pp. 206-208

Author(s):

Juan Carlos Jimenez ◽

Samuel Eric Wilson

Keyword(s):

Critical Limb Ischemia ◽

Multidisciplinary Care ◽

Limb Ischemia ◽

Free Survival ◽

Chronic Critical Limb Ischemia

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Functional prognosis of critical limb ischemia and efficacy of restoration of direct flow below the ankle

Vascular ◽

10.1177/1708538118798886 ◽

2018 ◽

Vol 27 (1) ◽

pp. 38-45

Author(s):

Tadashi Furuyama ◽

Toshihiro Onohara ◽

Ryosuke Yoshiga ◽

Keiji Yoshiya ◽

Yutaka Matsubara ◽

...

Keyword(s):

Endovascular Therapy ◽

Critical Limb Ischemia ◽

Ulcer Healing ◽

Therapy Group ◽

Limb Ischemia ◽

Direct Flow ◽

Free Survival ◽

Ambulatory Status ◽

Bypass Group ◽

One Year

Objective Patients with critical limb ischemia have serious systemic comorbidities and are at high risk of impairment of limb function. In this study, we assessed the prognostic factors of limbs after revascularization. Methods In this retrospective single-center cohort study, from April 2008 to December 2012, we treated 154 limbs of 121 patients with critical limb ischemia by the endovascular therapy-first approach based on the patients’ characteristics. The primary end point was amputation-free survival. Secondary end points were patency of a revascularized artery, major adverse limb events, or death. Furthermore, we investigated the ambulatory status one year after revascularization as prognosis of limb function. Results Endovascular therapy was performed in 85 limbs in 65 patients as the initial therapy (endovascular therapy group) and surgical reconstructive procedures (bypass group) were performed in 69 limbs in 56 patients. Early mortality within 30 days was not observed in either group. The primary patency rate was significantly better in the bypass group than in the endovascular therapy group ( p < 0.0001). Furthermore, the secondary patency rate was similar between the two groups ( p = 0.0096). There were no significant differences in amputation-free survival and major adverse limb event between the two groups. Univariate analysis showed that ulcer healing ( p < 0.0001), no hypoalbuminemia ( p = 0.0019), restoration of direct flow below the ankle ( p = 0.0219), no previous cerebrovascular disease ( p = 0.0389), and Rutherford 4 ( p = 0.0469) were predictive factors for preservation of ambulatory status one year after revascularization. In multivariate analysis, ulcer healing ( p < 0.0001) and restoration of direct flow below the ankle ( p = 0.0060) were significant predictors. Conclusions Ulcer healing and restoration of direct flow below the ankle are independently associated with prognosis of limb functions in patients who undergo infrainguinal arterial reconstruction.

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Evaluation of foot hypoperfusion and estimation of percutaneous transluminal angioplasty outcome in patients with critical limb ischemia using intravoxel incoherent motion microperfusion MRI

British Journal of Radiology ◽

10.1259/bjr.20210215 ◽

2021 ◽

pp. 20210215

Author(s):

Nikolaos Galanakis ◽

Thomas G Maris ◽

Georgios Kalaitzakis ◽

Nikolaos Kontopodis ◽

Nikolas Matthaiou ◽

...

Keyword(s):

Critical Limb Ischemia ◽

Percutaneous Transluminal Angioplasty ◽

Ankle Brachial Index ◽

Limb Ischemia ◽

Transluminal Angioplasty ◽

Lower Limbs ◽

Intravoxel Incoherent Motion ◽

Healthy Individuals ◽

Imaging Protocol ◽

Percutaneous Transluminal

Objectives: To emerge hypoperfusion of lower limbs in patients with critical limb ischemia (CLI) using Intravoxel Incoherent Motion microperfusion magnetic resonance imaging (IVIM-MRI). Moreover to examine the ability of IVIM-MRI to differentiate patients with severe peripheral arterial disease (PAD) from normal subjects and evaluate the percutaneous transluminal angioplasty (PTA) results in patients with CLI. Methods: Eight patients who presented with CLI and six healthy volunteers were examined. The patients underwent IVIM-MRI of lower extremity before and following PTA. The imaging protocol included sagittal diffusion-weighted (DW) sequences. DW images were analyzed and color parametric maps of the micro-circulation of blood inside the capillary network (D*) were constructed. The studies were evaluated by two observers to define interobserver reproducibility. Results: Technical success was achieved in all patients (8/8). The mean ankle-brachial index increased from 0.35 ± 0.2 to 0.76 ± 0.25 (p < 0.05). Successful revascularization improved IVIM microperfusion. Mean D* increased from 279.88 ± 13.47 10−5 mm2/s to 331.51 ± 31 10−5 mm2/s, following PTA, p < 0.05. Moreover, PAD patients presented lower D* values as compared to healthy individuals (279.88 ± 13.47 10−5 mm2/s vs 332.47 ± 22.95 10−5 mm2/s, p < 0.05, respectively). Good interobserver agreement was obtained with an ICC = 0.84 (95% CI 0.64–0.93). Conclusions: IVIM-MRI can detect differences in microperfusion between patients with PAD and healthy individuals. Moreover, significant restitution of IVIM microperfusion is found following successful PTA. Advances in knowledge: IVIM-MRI is a safe, reproducible and effective modality for evaluation of lower limb hypoperfusion in patients with PAD. It seems also to be a helpful tool to detect changes of tissue perfusion in patients with CLI following revascularization.

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Comparison of Results in Endovascular Interventions for Infrainguinal Lesions: Claudication versus Critical Limb Ischemia

The American Surgeon ◽

10.1177/000313480507100605 ◽

2005 ◽

Vol 71 (6) ◽

pp. 474-480 ◽

Cited By ~ 10

Author(s):

Susan M. Trocciola ◽

Rabih Chaer ◽

Rajeev Dayal ◽

Stephanie C. Lin ◽

Naveen Kumar ◽

...

Keyword(s):

Limb Salvage ◽

Critical Limb Ischemia ◽

Clinical Success ◽

Ankle Brachial Index ◽

Duplex Ultrasound ◽

Limb Ischemia ◽

Arterial Disease ◽

Transluminal Angioplasty ◽

Primary Patency ◽

Endovascular Interventions

This study analyzed clinical success, patency, and limb salvage after endovascular repair in patients treated for chronic limb ischemia presenting with claudication versus critical limb ischemia. Between October 2001 and August 2004, 115 patients (mean age 71) underwent endovascular treatment for infrainguinal arterial disease. Techniques included subintimal angioplasty and transluminal angioplasty with or without stents. Lesions were classified according to Transatlantic InterSociety Consensus. Follow-up (mean 11 months) included physical exam, ankle-brachial index, and duplex ultrasound. Patency rates were determined using Kaplan-Meier and compared by log-rank analysis. One hundred ninety-nine lesions were treated in 121 limbs using percutaneous techniques. Comorbidities were similar except higher rates of diabetes mellitus (67% vs 41%, P < 0.001) and chronic renal insufficiency (22% vs 7%, P < 0.05) were found in critical limb ischemia patients. Primary patency for claudicants was 100 per cent, 98 per cent, and 85 per cent at 3, 6, and 12 months and 89 per cent, 80 per cent, and 72 per cent for critical limb ischemia, respectively ( P = 0.06). Limb salvage was 91 per cent at 12 months for critical limb ischemia patients. Morbidity was similar between groups, and there was no perioperative mortality. Percutaneous intervention for both claudication and critical limb ischemia provides acceptable 12-month patency with limited morbidity.

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P3571Comparable limb salvage and amputation free survival in diabetic and non-diabetic patients with critical limb ischemia undergoing endovascular revascularization

European Heart Journal ◽

10.1093/eurheartj/ehy563.p3571 ◽

2018 ◽

Vol 39 (suppl_1) ◽

Author(s):

B P Y Yan ◽

W M Chan ◽

W H S Lai ◽

A O W Cheng ◽

C K Y Chan ◽

...

Keyword(s):

Limb Salvage ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Diabetic Patients ◽

Free Survival ◽

Endovascular Revascularization

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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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