Poor survival of dialysis patients with unhealed wounds because of critical limb ischemia: Limb salvage and survival requires wound healing

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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Endovascular revascularization of multilevel arterial disease in patients with critical limb ischemia

International Surgery Journal ◽

10.18203/2349-2902.isj20182025 ◽

2018 ◽

Vol 5 (6) ◽

pp. 2039

Author(s):

Asser Abd El Hamid Goda

Keyword(s):

Wound Healing ◽

Limb Salvage ◽

Critical Limb Ischemia ◽

Healing Rate ◽

Limb Ischemia ◽

Arterial Disease ◽

Endovascular Revascularization ◽

The Mean ◽

Revascularization Procedures ◽

Salvage Rate

Background: Critical limb ischemia (CLI) occurs due to progressive obstructive nature of atherosclerosis disease. Nowadays, there is widespread use of endovascular revascularization procedures for restoration of blood flow in CLI. The aim this study is evaluation of the efficacy of endovascular intervention for multilevel arterial disease in patients with critical limb ischemia.Methods: This prospective study was included CLI patients due to multilevel arterial disease who underwent endovascular revascularization between January 2016 and January 2017 in our institution. Study end points were limb salvage and wound healing. Results: The mean age of patients was (61.7±7.47) years, with 13 (61.9%) men. Eight limbs were identified as Rutherford category 4 (38.1%), ten limbs as Rutherford category 5 (47.6%), and three limbs as Rutherford category 6 (14.3%). Limb salvage rate was (90.5%) at 1 year. Wound healing rate was 80.9%.Conclusions: This study proved that endovascular revascularization of multilevel arterial disease for patients with critical limb ischemia is effective.

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Endovascular reconstruction of popliteal and infrapopliteal arteries for limb salvage and wound healing in patients with critical limb ischemia – A retrospective analysis

Indian Heart Journal ◽

10.1016/j.ihj.2015.07.024 ◽

2016 ◽

Vol 68 (1) ◽

pp. 77-82 ◽

Cited By ~ 4

Author(s):

Uday B. Khanolkar ◽

Biju Ephrem

Keyword(s):

Wound Healing ◽

Retrospective Analysis ◽

Limb Salvage ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Infrapopliteal Arteries

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Surgical Revascularization in Patients with End-Stage Renal Disease: Results Using a New Paradigm in Outcomes Assessment

The American Surgeon ◽

10.1177/000313480707300612 ◽

2007 ◽

Vol 73 (6) ◽

pp. 598-605

Author(s):

Wesley B. Jones ◽

David L. Cull ◽

Corey A. Kalbaugh ◽

Anna L. Cass ◽

Spence M. Taylor

Keyword(s):

Wound Healing ◽

Renal Disease ◽

Limb Salvage ◽

Critical Limb Ischemia ◽

End Stage Renal Disease ◽

Limb Ischemia ◽

Graft Patency ◽

Surgical Revascularization ◽

Stage Renal Disease ◽

End Stage

Studies evaluating the outcome of surgical revascularization (SR) for critical limb ischemia in patients who have end-stage renal disease (ESRD) have differed widely in their findings and conclusions. Differences in definitions of success are largely responsible for the varying outcomes. We developed a method of outcomes assessment that incorporates four all-inclusive end-points to define success. These include primary graft patency to the point of wound healing, postoperative survival of at least 6 months, limb salvage of at least 1 year, and maintenance of ambulatory status of at least 6 months. The purpose of this study was to use this novel method of defining success to determine the outcome of SR in patients with ESRD. From 1998 to 2004, 40 patients (52 limbs) with ESRD and tissue loss underwent SR for limb salvage. Secondary graft patency and limb salvage rates at 36 months were 54.7 per cent and 53 per cent, respectively. When considering each of the four components used to define success separately, success encouragingly ranged between 60 per cent (patent graft until wound healing) and 87.5 per cent (survival for 6 months). However, if all parameters were combined, clinical success was achieved in only 40 per cent (16/40) of patients. Coronary artery disease was the only factor found to significantly reduce success ( P = 0.04). In conclusion, using this multiparameter definition of success, which combines four rather modest outcome milestones, favorable outcome occurred in the minority of cases. This study challenges our current method of analyzing success and questions our therapeutic approach to patients with critical limb ischemia and ESRD.

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Wound healing of critical limb ischemia with tissue loss in patients on hemodialysis

Vascular ◽

10.1177/1708538116673015 ◽

2016 ◽

Vol 25 (3) ◽

pp. 272-282 ◽

Cited By ~ 4

Author(s):

Yohsuke Honda ◽

Keisuke Hirano ◽

Masahiro Yamawaki ◽

Shinsuke Mori ◽

Shigemitsu Shirai ◽

...

Keyword(s):

Wound Healing ◽

Limb Salvage ◽

Critical Limb Ischemia ◽

Healing Rate ◽

Young Patients ◽

Limb Ischemia ◽

Tissue Loss ◽

Wound Recurrence ◽

Healing Wound ◽

Wound Healing Rate

We assessed wound healing in patients on hemodialysis (HD) with critical limb ischemia (CLI). This study enrolled 267 patients (including 120 patients on HD and 147 patients not on HD) who underwent endovascular therapy (EVT) for CLI. The primary endpoint was wound-healing rate at two years. Secondary endpoints were time to wound healing, wound recurrence rate, and limb salvage at two years. The percentage of male and young patients was higher in the HD patients ( p < 0.01). A lower patency of the pedal arch after EVT was observed frequently in HD patients ( p < 0.01). The wound-healing rate was significantly lower in HD patients (79.5% vs. 92.4%, p < 0.001). Time to wound healing was significantly longer in HD patients (median 132 days vs. 82 days, p = 0.005). Wound recurrence was observed more frequently in HD patients (25.0% vs. 10.2%, p = 0.007). Limb salvage (72.8% vs. 86.4%, p = 0.002) was significantly lower in HD patients. In a cox proportional hazard model, HD was an independent predictor of wound healing (risk ratio (RR), 0.46; 95% confidence interval (CI), 0.33–0.62; p < 0.001) and wound recurrence (RR, 1.58; 95% CI, 1.11–2.22; p = 0.01). HD was independently associated with lower and delayed wound healing, and wound recurrence.

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Hybrid Foot Vein Arterialization in No-Option Patients With Critical Limb Ischemia: A Preliminary Report

Journal of Endovascular Therapy ◽

10.1177/1526602818820792 ◽

2018 ◽

Vol 26 (1) ◽

pp. 7-17 ◽

Cited By ~ 9

Author(s):

Roberto Ferraresi ◽

Andrea Casini ◽

Fabrizio Losurdo ◽

Maurizio Caminiti ◽

Alessandro Ucci ◽

...

Keyword(s):

Wound Healing ◽

Limb Salvage ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Major Amputation ◽

Below The Knee ◽

Surgical Bypass ◽

Foot Lesions ◽

Wound Classification ◽

Grade 3

Purpose: To describe a preliminary experience in treating no-option critical limb ischemia (CLI) patients with a hybrid foot vein arterialization (HFVA) technique combining open plus endovascular approaches. Materials and Methods: Between May 2016 and January 2018, 35 consecutive patients (mean age 68±12 years; 28 men) with 36 no-option CLI limbs underwent HFVA in our center. All limbs had grade 3 WIfI (Wound, Ischemia, and foot Infection) ischemia, and the wound classification was grade 1 in 4 (11%) limbs, grade 2 in 4 (11%), and grade 3 in 28 (78%). Surgical bypass was done on the medial marginal vein or a posterior tibial vein, followed by endovascular removal of foot vein valves and embolization of foot vein collaterals. A “tension-free” surgical approach was used to treat foot lesions. Results: At a mean follow-up of 10.8±2 months, limb salvage was achieved in 25 (69%) limbs and wound healing in 16 (44%); 9 patients presented an unhealed wound. Eleven (31%) patients underwent a major amputation (2 below the knee and 9 thigh). One patient with an unhealed wound and open bypass died of myocardial infarction. Conclusion: HFVA is a promising technique able to achieve acceptable rates of limb salvage and wound healing in no-option patients generally considered candidates for an impending major amputation. Further studies are needed to standardize the technique and better identify patients who can benefit from this approach.

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