Perfusion Assessment in Critical Limb Ischemia: Principles for Understanding and the Development of Evidence and Evaluation of Devices: A Scientific Statement From the American Heart Association

There are >12 million patients with peripheral artery disease in the United States. The most severe form of peripheral artery disease is critical limb ischemia (CLI). The diagnosis and management of CLI is often challenging. Ethnic differences in comorbidities and presentation of CLI exist. Compared with white patients, black and Hispanic patients have higher prevalence rates of diabetes mellitus and chronic renal disease and are more likely to present with gangrene, whereas white patients are more likely to present with ulcers and rest pain. A thorough evaluation of limb perfusion is important in the diagnosis of CLI because it can not only enable timely diagnosis but also reduce unnecessary invasive procedures in patients with adequate blood flow or among those with other causes for ulcers, including venous, neuropathic, or pressure changes. This scientific statement discusses the current tests and technologies for noninvasive assessment of limb perfusion, including the ankle-brachial index, toe-brachial index, and other perfusion technologies. In addition, limitations of the current technologies along with opportunities for improvement, research, and reducing disparities in health care for patients with CLI are discussed.

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Faculty Opinions recommendation of Pathology of peripheral artery disease in patients with critical limb ischemia.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.733896223.793553737 ◽

2018 ◽

Author(s):

Joseph Emmerich

Keyword(s):

Peripheral Artery Disease ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Peripheral Artery ◽

Artery Disease

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Angiogenin—A Proposed Biomarker for Cardiovascular Disease—Is Not Associated With Long-Term Survival in Patients With Peripheral Artery Disease

Angiology ◽

10.1177/00033197211004393 ◽

2021 ◽

pp. 000331972110043

Author(s):

Clemens Höbaus ◽

Gerfried Pesau ◽

Bernhard Zierfuss ◽

Renate Koppensteiner ◽

Gerit-Holger Schernthaner

Keyword(s):

Peripheral Artery Disease ◽

Cox Regression ◽

Ankle Brachial Index ◽

Limb Ischemia ◽

Cross Sectional Study ◽

Enzyme Linked Immunosorbent Assay ◽

Peripheral Artery ◽

Cross Sectional ◽

Term Survival ◽

Artery Disease

We evaluated angiogenin as a prospective biomarker in peripheral artery disease (PAD) patients with and without claudication symptoms. A pilot study suggested an elevation of angiogenin in critical limb ischemia. However, in PAD patients, the predictive value of angiogenin has not yet been evaluated. For this purpose, 342 patients with PAD (age: 69 ± 10 years, 34.5% women) were followed-up for 7 years in a cross-sectional study. Angiogenin was measured by enzyme-linked immunosorbent assay. All-cause and cardiovascular mortality were analyzed by Cox regression. Angiogenin levels were higher in men ( P = .001) and were associated with patient waist-to-hip ratio ( P < .001), fasting triglycerides ( P = .011), and inversely with estimated glomerular filtration rate ( P = .009). However, angiogenin showed no association with age, characteristics of diabetes, markers of lipid metabolism, or C-reactive protein. Angiogenin did not correlate with markers of angiogenesis such as vascular endothelial growth factor, angiopoietin-2, or tie-2. Furthermore, angiogenin was not associated with PAD Fontaine stages or with patient ankle-brachial index in addition to all-cause mortality (hazard ratio [HR] = 1.09 [95% CI: 0.89-1.34]) or cardiovascular morality (HR = 1.05 [0.82-1.35]). These results suggest that angiogenin does not provide further information regarding outcome prediction in patients with PAD.

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Multi-Level Lower Extremity Arterial Revascularization Via Retrograde Pedal Access Under Local Anesthesia in a Patient With Severe Cardiopulmonary Comorbidities: A Case Report

Vascular and Endovascular Surgery ◽

10.1177/15385744211026451 ◽

2021 ◽

pp. 153857442110264

Author(s):

Hee Korleski ◽

Laura DiChiacchio ◽

Luiz Araujo ◽

Michael R. Hall

Keyword(s):

Case Report ◽

General Anesthesia ◽

Peripheral Artery Disease ◽

Critical Limb Ischemia ◽

Treatment Modality ◽

Conventional Treatment ◽

Limb Ischemia ◽

Peripheral Artery ◽

Endovascular Revascularization ◽

Artery Disease

Background: Chronic limb-threatening ischemia is a severe form of peripheral artery disease that leads to high rates of amputation and mortality if left untreated. Bypass surgery and antegrade endovascular revascularization through femoral artery access from either side are accepted as conventional treatment modalities for critical limb ischemia. The retrograde pedal access revascularization is an alternative treatment modality useful in specific clinical scenarios; however, these indications have not been well described in literature. This case report highlights the use of retrograde pedal access approach as primary treatment modality in a patient with an extensive comorbidities precluding general anesthesia nor supine positioning. Case Presentation: The patient is a 60-year-old female with multiple severe cardiopulmonary comorbidities presenting with dry gangrene of the right great toe. Her comorbidities and inability to tolerate supine positioning precluded her from receiving open surgery, general anesthesia or monitored sedation, or percutaneous femoral access. Rather, the patient underwent ankle block and retrograde endovascular revascularization via dorsalis pedis artery access without post-operative complications. Discussion: The prevalence of comorbidities related to peripheral artery disease is increasing and with it the number of patients who are not optimal candidates for conventional treatment methods for critical limb ischemia. The retrograde pedal access revascularization as initial treatment modality offers these patients an alternative limb salvaging treatment option.

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