Chronic limb ischaemia

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.

Minimising failure in critical lower limb ischaemia intervention: Adjuvant capillary bed recruitment is the missed opportunity

Vascular ◽  
2018 ◽  
Vol 26 (4) ◽  
pp. 449-454
Author(s):  
Sherif Sultan ◽  
Edel Patricia Kavanagh ◽  
Niamh Hynes
Keyword(s):  
Lower Limb ◽  
Peripheral Circulation ◽  
Arterial Disease ◽  
Muscle Disease ◽  
Critical Limb Ischaemia ◽  
High Morbidity ◽  
Limb Ischaemia ◽  
Lower Limb Ischaemia ◽  
Capillary Bed ◽  
Peripheral Arterial

Critical limb ischaemia is the end stage of peripheral arterial disease before limb loss. Contemporary interventions to restore blood flow have high morbidity and mortality and fail to provide sustained restoration of peripheral circulation. Cell-based therapies designed to promote neovascularisation or angiogenesis have been shown in trials to be safe but clinically ineffective. Notwithstanding endless research in the area, no headway has been made in identifying a successful therapy designed specifically to target muscle disease in critical lower limb ischaemia. Thus, the quest to find an effective, lasting solution for critical lower limb ischaemia continues and requires more innovative therapeutic tactics. Our aim is to highlight the crucially interlinked role of the capillary bed, skeletal muscle mass and mitochondria in critical lower limb ischaemia patients and to identify novel therapeutic mechanisms that the vascular interventionalist can add to their armamentarium.

Overview of Treatment Options for Critical Limb Ischaemia Patients

2011 ◽  
Vol 7 (1) ◽  
pp. 51 ◽  
Author(s):  
Frederic Baumann ◽  
Nicolas Diehm ◽  
◽  
Keyword(s):  
Treatment Options ◽  
Critical Limb Ischaemia ◽  
Treatment Modalities ◽  
High Morbidity ◽  
Limb Ischaemia ◽  
Arterial Revascularisation ◽  
Planning Treatment ◽  
Treatment Concepts ◽  
Peripheral Arterial ◽  
Renal Origin

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.

scholarly journals Predictors of post-operative outcomes in patients with peripheral arterial disease and critical limb ischaemia: a systematic review and meta-analysis

2021 ◽  
Vol 55 (1) ◽  
pp. 69-76
Author(s):  
Lily P. Wu ◽  
Nadraj G. Naidoo ◽  
Olatunji O. Adetokunboh
Keyword(s):  
Peripheral Arterial Disease ◽  
Limb Salvage ◽  
Graft Patency ◽  
Arterial Disease ◽  
Critical Limb Ischaemia ◽  
Wound Complications ◽  
Limb Ischaemia ◽  
Operative Outcomes ◽  
One Year ◽  
Peripheral Arterial

Background: A very small proportion (1%) of patients with peripheral artery disease (PAD) present with critical limb threatening ischaemia (CLTI) with poor prognosis. The present review showcased several pre-operative predictors and key post-operative outcomes. Identification of any modifiable predictors may impact positively on surgical outcomes.Design: PubMed/Medline, Google scholar and Cochrane databases were searched using terms such as “peripheral arterial disease” AND “critical limb ischemia,” “post-operative outcome,” AND “predictors of post-operative outcomes”. Search was for relevant English-language articles published between January 1997 and December 2007 Selected articles were screened first by title and abstract, and selection of full articles was based on relevance using our inclusion and exclusion criteria and quality ratings performed with the MINORS score.Results: The included studies were published between 1997 and 2007. Only six (6) articles out of a total of 2,114 were deemed suitable for analysis. Ambulatory recovery was >70% at six months, 86.7% and 70.0% at one year and five years respectively. Rate of local wound complications was between 12% and 24%. Reported limb salvage rates were >90% at six months, >70% at one year and 70.0-90.0% at five years. Primary graft patency rate at one year ranged from 63% and 76.6%. Gangrene, diabetes and impaired pre-operative ambulatory function are associated with more wound complications, low limb salvage, reduced graft patency and poor functional outcome.Conclusion: Pre-operative ambulatory status was the most important predictor of post-operative ambulatory recovery. Diabetes mellitus was an important risk factor for prolonged wound healing, local wound complications and major amputation.

Thrombophilic risk factors and peripheral arterial disease severity

2010 ◽  
Vol 104 (07) ◽  
pp. 71-77 ◽  
Author(s):  
Elisabetta Favaretto ◽  
Cristina Legnani ◽  
Michela Cini ◽  
Eleonora Conti ◽  
Alfio Amato ◽  
...  
Keyword(s):  
Risk Factors ◽  
Peripheral Arterial Disease ◽  
Arterial Disease ◽  
Cross Sectional Study ◽  
Critical Limb Ischaemia ◽  
Limb Ischaemia ◽  
Cross Sectional ◽  
G20210a Mutation ◽  
Peripheral Arterial ◽  
Few Data

SummaryFew data are available on thrombophilic risk factors and progression of atherosclerotic peripheral arterial disease (PAD). Thrombophilic alterations can be an aggravating factor when arterial stenoses are present. In a cross-sectional study, we evaluated the presence of the thrombophilic factors fibrinogen, homocysteine, factor (F)VIII, lupus anticoagulant (LAC), FII G20210A, and FV R506Q mutations in 181 patients with PAD at Fontaine’s stage II (claudication), in 110 patients with critical limb ischaemia (CLI), and in 210 controls. Fibrinogen was higher in patients with CLI vs. those with claudication and controls (427.9 ± 10.5 vs. 373.1 ± 5.2 vs. 348.9 ± 7.0 p=0.001, respectively). Homocysteine and FVIII were higher in patients with PAD than in controls, but were similar in patients with CLI and claudication. The prevalence of LAC increased in patients with CLI vs. those with claudication and controls (21.4% vs. 7.8% vs. 5.2% p<0.001, respectively). The prevalence of FII 20210A allele was higher in patients with CLI vs. those with claudication and controls. Using a logistic model, FII G20210A mutation (odds ratio [OR] 19.8, confidence interval [CI] 4.5–87.1, p=0.001), LAC (OR 2.7, CI1.1–6.5, p=0.032), and fibrinogen (OR 1.01, CI 1.00–1.01, p=0.001) were associated with CLI, whereas homocysteine, FVIII, and FV R506Q mutation were not. CLI risk increased according to the number of thrombophilic alterations. In conclusion, altered levels of some important thrombophilic risk factors are independently associated with PAD severity. These data suggest that the presence of two or more thrombophilic risk factors raise the likelihood of PAD being more severe, justifying the need for larger longitudinal studies.

Are there predictors for the outcome of a PGE1 treatment in peripheral arterial disease with critical limb ischaemia?

VASA ◽  
2005 ◽  
Vol 34 (2) ◽  
pp. 101-107 ◽  
Author(s):  
Heidrich ◽  
Schmidt ◽  
Fahrig
Keyword(s):  
Peripheral Arterial Disease ◽  
Arterial Disease ◽  
Vascular Reconstruction ◽  
Clinical Analysis ◽  
Critical Limb Ischaemia ◽  
Limb Ischaemia ◽  
Prior Therapy ◽  
Predictors Of Response ◽  
Peripheral Arterial ◽  
Vascular Occlusions

Background: In a multivariate retrospective analysis was conducted to examine whether and to what extent PGE1 is therapeutically effective and whether there are predictors of response. Patients and methods: The examination included 767 patients (448 women, 319 men) of a mean age of 71.2 years and with peripheral arterial disease (PAD) having existed for 44.7 months on the average. They suffered from critical limb ischaemia (Fontaine’s stages III/IV) and showed average tcpO2 values at the instep of 2 mmHg (0 to 15) and average systolic malleolar artery pressures of 18 mmHg (0 to 35 mmHg). Between 1989 and 2001, the patients had received treatments in hospital with i.v. PGE1 doses (2 x 20 mug or 1 x 60 mug/day) for an average of 34.2 days (mean of responder- and non-responder group). Patients were called responders when pain had markedly decreased or disappeared, necroses had been reduced or healed completely, and vascular reconstruction, PTA or amputations were not necessary. Results: The clinical analysis showed 82.4% of the patients to be responders and 17.6% to be non-responders. It was demonstrated that the outcome of the therapy was not dependent on the supine or sitting tcpO2, the malleolar artery pressure, the patient’s age or sex, the duration of PAD, the number or kind of concomitant diseases, the patient’s general condition, the localization and number of vascular occlusions, the kind of prior therapy, or the number of previous amputations, although differences in some of the parameters, while clinically irrelevant, were found to be statistically significant. They are not predictors of the outcome of a PGE1 therapy. Conclusions: Even in extremely bad haemodynamic situations at the beginning of a therapy (malleolar artery pressures from 0 to 35 mmHg, tcpO2 0 to 15 mmHg, multilevel occlusive disease, multiple previous operations and concomitant diseases), PGE1 therapies of more than 20 days – on the average 35.6 days (mean of responder group) – duration allow clinically relevant positive results to be achieved.

Antiphospholipid antibodies and lower extremity peripheral arterial disease - a systematic review and meta-analysis

VASA ◽  
2016 ◽  
Vol 45 (4) ◽  
pp. 325-330 ◽  
Author(s):  
Beatriz Gavier ◽  
Fernando Vazquez ◽  
Esteban Gandara
Keyword(s):  
Systematic Review ◽  
Peripheral Arterial Disease ◽  
Lower Extremity ◽  
Antiphospholipid Antibodies ◽  
Meta Analysis ◽  
Arterial Disease ◽  
Critical Limb Ischaemia ◽  
Limb Ischaemia ◽  
Disease Case ◽  
Peripheral Arterial

Abstract. Background: Despite being an important risk factor for venous thromboembolism and ischaemic stroke, the role of antiphospholipid antibodies in patients with peripheral arterial disease remains a matter of debate. The aim of this study was to evaluate the association of persistently elevated antiphospholipid antibodies and lower extremity peripheral arterial disease. Methods: We conducted a systematic review of electronic databases including MEDLINE, EUROPUBMED and EMBASE to assess the prevalence of antiphospholipid antibodies in patients with lower extremity peripheral arterial disease. Case-control studies were included if they reported the prevalence of antiphospholipid antibodies in patients with lower extremity peripheral arterial disease. Two reviewers (FV and EG) independently assessed the eligibility of all articles. The primary outcome measure was the odds ratio (OR) for the prevalence of antiphospholipid antibodies patients with lower extremity peripheral arterial disease, along with the corresponding 95 % confidence intervals (CIs). Results: Our initial electronic search identified 128 relevant abstracts, of which two studies were included. Antiphospholipid antibodies were found in 50/571 patients with lower extremity peripheral arterial disease and 13/490 of the controls, OR 3.32 (95 % CI = 1.49 to 7.4). In those with critical limb ischaemia, the prevalence of antiphospholipid antibodies was elevated compared to controls, pooled OR 4.78 (95 % CI = 2.37 to 9.65). Conclusions: Our systematic review and meta-analysis suggests that the prevalence of persistently elevated levels of antiphospholipid antibodies is increased in patients with lower extremity peripheral diseases when compared to healthy controls, especially in those with critical limb ischaemia.

Epidemiology and global burden of peripheral arterial disease and aortic aneurysms

ESC CardioMed ◽  
2018 ◽  
pp. 328-334
Author(s):  
Holger Reinecke ◽  
Nasser Malyar
Keyword(s):  
General Population ◽  
Large Scale ◽  
Arterial Disease ◽  
Aortic Aneurysms ◽  
Critical Limb Ischaemia ◽  
Limb Ischaemia ◽  
Thoracic Aortic Aneurysms ◽  
Artery Disease ◽  
Peripheral Arterial ◽  
Older Populations

Peripheral artery disease (PAD) and aortic aneurysms are common diseases in older populations, sharing common aetiological risk factors. From community-based trials assessing ankle–brachial indices, 2–4% of the general population have been shown to be affected by PAD, which increases up to 15% in those above 70 years of age. About 30–40% of the in-hospital cases with PAD have critical limb ischaemia and suffer from a 1-year mortality of 20–40%. Abdominal aortic aneurysms (AAAs) also show a relatively high prevalence of about 1–2% in the general population as found by large-scale, systematic duplex screening. Of these, about 5% come to hospital admittance with a ruptured AAA which is still associated with an in-hospital mortality of up to 50%. The prevalence of thoracic aortic aneurysms (TAAs) was reported to be at about 0.16–0.34% in selected subgroups of the general population. The incident cases of TAAs have risen from 10/100,000 cases in the late 1980s up to about 17/100,000 cases in the first decade of this millennium. It is noteworthy that PAD and aortic aneurysms as well as their associated co-morbidities remain in many cases underdiagnosed and undertreated. This leads to a high cardiovascular morbidity and mortality which could not be obviously markedly reduced in the recent decades. Since nearly all vascular disorders are systemic diseases, not only the specific vessel bed which leads to a presentation should be assessed but also all other possible vascular manifestations should be thoroughly examined to reduce the high rates of adverse events and the persistent poor outcome.

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