Differences Between Patients With Intermittent Claudication and Critical Limb Ischemia Undergoing Endovascular Intervention: Insights From the Excellence in Peripheral Artery Disease Registry

Background: There are limited data on differences in angiographic distribution of peripheral artery disease and endovascular revascularization strategies in patients presenting with intermittent claudication (IC) and critical limb ischemia (CLI). We aimed to compare anatomic features, treatment strategies, and clinical outcomes between patients with IC and CLI undergoing endovascular revascularization. Methods: We examined 3326 patients enrolled in the Excellence in Peripheral Artery Disease registry from 2006 to 2019 who were referred for endovascular intervention for IC (n=1983) or CLI (n=1343). The primary outcome was 1-year major adverse limb events, which included death, repeat target limb revascularization, or target limb amputation. Results: Patients with CLI were older and more likely to have diabetes and chronic kidney disease and less likely to receive optimal medical therapy compared with IC. Patients with IC had higher femoropopliteal artery interventions (IC 87% versus CLI 65%; P <0.001), while below the knee interventions were more frequent in CLI (CLI 47% versus IC 12%; P <0.001). Patients with CLI were more likely to have multilevel peripheral artery disease (CLI 32% versus IC 15%, P <0.001). Patients with IC were predominantly revascularized with stents (IC 48% versus CLI 37%; P <0.001) while balloon angioplasty was more frequent in CLI (CLI 37% versus IC 25%; P <0.001). All-cause mortality was higher in patients with CLI (CLI 4% versus IC 2%; P =0.014). Major adverse limb event rates for patients with IC and CLI were 16% and 26%, respectively ( P <0.001) and remained higher in CLI after multivariable adjustment of baseline risk factors. Conclusions: Patients with IC and CLI have significant anatomic, lesion, and treatment differences with significantly higher mortality and adverse limb outcomes in CLI. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01904851.

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Characteristics and outcomes of patients with peripheral artery disease undergoing endovascular revascularization: A community hospital perspective

Vascular ◽

10.1177/1708538120958858 ◽

2020 ◽

pp. 170853812095885

Author(s):

S Michael Gharacholou ◽

Zhuo Li ◽

Jonathan J Uy ◽

Lee H Eckstein ◽

Carolyn R Flock ◽

...

Keyword(s):

Intermittent Claudication ◽

Peripheral Artery Disease ◽

Critical Limb Ischemia ◽

Community Hospital ◽

Limb Ischemia ◽

Study Cohort ◽

Acute Limb Ischemia ◽

Peripheral Artery ◽

Endovascular Revascularization ◽

Artery Disease

Background There are limited data on outcomes for patients with peripheral artery disease undergoing endovascular revascularization by multi-disciplinary teams in a community hospital setting. Methods From January 2015 through December 2015, we assembled a multi-disciplinary program comprised of cardiologists, surgeons, radiologists, nurses, and administrative staff for managing patients with peripheral artery disease undergoing endovascular revascularization. Demographic, procedural, and outcomes data were collected with use of a template from the Society for Vascular Surgery Vascular Quality Initiative database. We compared characteristics and outcomes of patients with intermittent claudication and critical limb ischemia. We used Kaplan–Meier methods to estimate the rate of overall survival and freedom from rehospitalization between groups. Results After excluding patients with acute limb ischemia ( n = 5), peripheral intervention to the upper extremity ( n = 6), or abdominal aorta ( n = 11), there were 82 patients in the study cohort; 45 had intermittent claudication and 37 had critical limb ischemia. Baseline and procedural characteristics were similar between groups, although critical limb ischemia patients were more likely to have hyperlipidemia (75.7% vs. 53.3%, P = .42). Procedural success was achieved in 91.3% of cases. Actionable access site bleeding occurred in 2.4% of patients. High rates of aspirin (91.5%) and statin (87.8%) were noted at discharge. After two years of post endovascular revascularization, survival was 57.5% for critical limb ischemia patients and 94.4% for intermittent claudication patients ( P < .001). Freedom from rehospitalization was 32.7% for critical limb ischemia patients and 83.5% for intermittent claudication patients ( P < .001). Conclusions We found that favorable outcomes may be achieved with a multi-disciplinary peripheral artery disease program at community hospitals. The incorporation of quality improvement practices may further help to develop standardized and regionalized approaches to care delivery for patients with peripheral artery disease.

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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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Pathophysiology of Peripheral Artery Disease, Intermittent Claudication, and Critical Limb Ischemia

Vascular Medicine: A Companion to Braunwald's Heart Disease ◽

10.1016/b978-1-4377-2930-6.00017-3 ◽

2013 ◽

pp. 223-230 ◽

Cited By ~ 4

Author(s):

William R. Hiatt ◽

Eric P. Brass

Keyword(s):

Intermittent Claudication ◽

Peripheral Artery Disease ◽

Critical Limb Ischemia ◽

Limb Ischemia ◽

Peripheral Artery ◽

Artery Disease

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Lower extremity revascularization via endovascular and surgical approaches: A systematic review with emphasis on combined inflow and outflow revascularization

SAGE Open Medicine ◽

10.1177/2050312120929239 ◽

2020 ◽

Vol 8 ◽

pp. 205031212092923

Author(s):

Jihad A Mustapha ◽

Bynthia M Anose ◽

Brad J Martinsen ◽

George Pliagas ◽

Joseph Ricotta ◽

...

Keyword(s):

Lower Extremity ◽

Peripheral Artery Disease ◽

Critical Limb Ischemia ◽

Treatment Options ◽

Limb Ischemia ◽

Medical Community ◽

Surgical Approaches ◽

Peripheral Artery ◽

Endovascular Revascularization ◽

Artery Disease

This review is intended to help clinicians and patients understand the present state of peripheral artery disease, appreciate the progression and presentation of critical limb ischemia/chronic limb-threatening ischemia, and make informed decisions regarding inflow and outflow endovascular revascularization and surgical treatment options within the context of current debates in the medical community. A controlled literature search was performed to obtain research on outcomes of critical limb ischemia patients undergoing complete leg revascularization for peripheral artery disease inflow and outflow disease. Data for this review were identified by queries of medical and life science databases, expert referral, and references from relevant papers published between 1997 and 2019, resulting in 48 articles. The literature review herein indicates that endovascular revascularization—including ballooning, stenting, and atherectomy—is an effective peripheral artery disease therapy for both above the knee and below the knee disease, and can safely and effectively treat both inflow and outflow disease. As such, it plays a leading role in the therapy of lower extremity artery disease.

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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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Advances in Revascularization for Peripheral Artery Disease: Revascularization in PAD

Circulation Research ◽

10.1161/circresaha.121.318261 ◽

2021 ◽

Vol 128 (12) ◽

pp. 1885-1912

Author(s):

Joshua A. Beckman ◽

Peter A. Schneider ◽

Michael S. Conte

Keyword(s):

Intermittent Claudication ◽

Peripheral Artery Disease ◽

Clinical Presentation ◽

Rapid Development ◽

Microvascular Disease ◽

Limb Ischemia ◽

Medical Emergency ◽

Acute Limb Ischemia ◽

Peripheral Artery ◽

Artery Disease

Effective revascularization of the patient with peripheral artery disease is about more than the procedure. The approach to the patient with symptom-limiting intermittent claudication or limb-threatening ischemia begins with understanding the population at risk and variation in clinical presentation. The urgency of revascularization varies significantly by presentation; from patients with intermittent claudication who should undergo structured exercise rehabilitation before revascularization (if needed) to those with acute limb ischemia, a medical emergency, who require revascularization within hours. Recent years have seen the rapid development of new tools including wires, catheters, drug-eluting technology, specialized balloons, and biomimetic stents. Open surgical bypass remains an important option for those with advanced disease. The strategy and techniques employed vary by clinical presentation, lesion location, and lesion severity. There is limited level 1 evidence to guide practice, but factors that determine technical success and anatomic durability are largely understood and incorporated into decision-making. Following revascularization, medical therapy to reduce adverse limb outcomes and a surveillance plan should be put in place. There are many hurdles to overcome to improve the efficacy of lower extremity revascularization, such as restenosis, calcification, microvascular disease, silent embolization, and tools for perfusion assessment. This review highlights the current state of revascularization in peripheral artery disease with an eye toward technologies at the cusp, which may significantly impact current practice.

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