Impact of Diabetes Mellitus on Critical Limb Ischemia With Below the Knee Disease: Japan Below-the-Knee Artery Treatment Subanalysis

Angiology ◽  
2013 ◽  
Vol 71 (5) ◽  
pp. 444-451 ◽  
Author(s):  
Kenji Suzuki ◽  
Osamu Iida ◽  
Yasutaka Yamauchi ◽  
Masatsugu Nakano ◽  
Yoshimitsu Soga ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Limb Salvage ◽  
Critical Limb Ischemia ◽  
Strong Association ◽  
Limb Ischemia ◽  
Major Amputation ◽  
Below The Knee ◽  
Younger Age ◽  
Diabetes Status ◽  
Significant Difference

Background: A strong association exists between diabetes mellitus and critical limb ischemia. Methods and Results: We performed endovascular therapy on 1060 limbs in 884 patients with below knee lesions only. The patients were divided into diabetes (DG) and nondiabetes groups (NDG). Limb salvage was poorer in the DG (79% vs 89%, P = .0061). No significant difference was observed in mortality, amputation-free survival (AFS), and target vessel revascularization (TVR). Multivariate analysis revealed diabetes status, infection, poor activity of daily living (ADL), younger age, and procedure failure as independent predictors of major amputation in DG. In the NDG, procedure failure was the predictor, and younger age and poor ADL showed tendency of major amputation. Conclusions: Mortality, AFS, and TVR showed no significant difference between the 2 groups, but major amputation was more frequent in DG. Not only revascularization but also infection and diabetes control were very important for limb salvage in DG.

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

2018 ◽  
Vol 26 (1) ◽  
pp. 7-17 ◽  
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.

Evaluation of Tissue Perfusion by Wound Blush and 2D Color-Coded Digital Subtraction Angiography During Endovascular Intervention and Its Impact on Limb Salvage in Critical Limb Ischemia

2021 ◽  
pp. 152660282110659
Author(s):  
Hassan Lotfy ◽  
Ahmed Abou El-Nadar ◽  
Wael Shaalan ◽  
Ali El Emam ◽  
Akram Ibrahim ◽  
...  
Keyword(s):  
Wound Healing ◽  
Digital Subtraction Angiography ◽  
Limb Salvage ◽  
Critical Limb Ischemia ◽  
Limb Ischemia ◽  
Tissue Perfusion ◽  
Technical Failure ◽  
Digital Subtraction ◽  
Reliable Technique ◽  
Significant Difference

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.

scholarly journals Below-knee endovascular interventions have better outcomes compared to open bypass for patients with critical limb ischemia

2016 ◽  
Vol 22 (1) ◽  
pp. 28-34 ◽  
Author(s):  
Caitlin W Hicks ◽  
Alireza Najafian ◽  
Alik Farber ◽  
Matthew T Menard ◽  
Mahmoud B Malas ◽  
...  
Keyword(s):  
Critical Limb Ischemia ◽  
Multivariable Analysis ◽  
Limb Ischemia ◽  
Major Amputation ◽  
Primary Patency ◽  
Tissue Loss ◽  
Vascular Intervention ◽  
Below The Knee ◽  
Endovascular Interventions ◽  
One Year

Both open surgery and endovascular peripheral interventions have been shown to effectively improve outcomes in patients with peripheral artery disease, but minimal data exist comparing outcomes performed at and below the knee. The purpose of this study was to compare outcomes following infrageniculate lower extremity open bypass (LEB) versus peripheral vascular intervention (PVI) in patients with critical limb ischemia. Using data from the 2008–2014 Vascular Quality Initiative, 1-year primary patency, major amputation, and mortality were compared among all patients undergoing LEB versus PVI at or below the knee for rest pain or tissue loss. Overall, 2566 patients were included (LEB=500, PVI=2066). One-year primary patency was significantly worse following LEB (73% vs 81%; p<0.001). One-year major amputation (14% vs 12%; p=0.18) and mortality (4% vs 6%; p=0.15) were similar regardless of revascularization approach. Multivariable analysis adjusting for baseline differences between groups confirmed inferior primary patency following LEB versus PVI (HR 0.74; 95% CI, 0.60–0.90; p=0.004), but no significant differences in 1-year major amputation (HR 1.06; 95% CI, 0.80–1.40; p=0.67) or mortality (HR 0.71; 95% CI, 0.44–1.14; p=0.16). Based on these data, we conclude that endovascular revascularization is a viable treatment approach for critical limb ischemia resulting from infrageniculate arterial occlusive disease.

scholarly journals Long-Term Results of Endovascular Femoropopliteal Interventions

2018 ◽  
Vol 27 (03) ◽  
pp. 151-157 ◽  
Author(s):  
Luke Marone ◽  
Robert Hacker
Keyword(s):  
Limb Salvage ◽  
Univariate Analysis ◽  
Limb Ischemia ◽  
Major Amputation ◽  
Long Term Results ◽  
Secondary Patency ◽  
Endovascular Interventions ◽  
Significant Difference ◽  
Societal Consensus

Background and Objective Short-term results of endovascular intervention for femoropopliteal lesions have been extensively reported; however, there exists a paucity of long-term objective data related to outcomes of these interventions. We sought to characterize these long-term results including patency, limb salvage, and mortality. Methods From May 2003 to July 2009, all patients who underwent technically successful endovascular balloon angioplasty and/or stenting for Trans-Atlantic Inter-Societal Consensus (TASC) II B, C, and D lesions were identified in a retrospective fashion. Patient demographics, clinical characteristics, arterial noninvasive data, and angiographic anatomic data were evaluated. Results A total of 236 limbs in 186 patients (mean age 74, range 37–94) were treated. Lesion distributions by TASC II classification B, C, and D were 121 (51.3%), 37 (15.7%), and 78 (33%), respectively. Critical limb ischemia (CLI) was the indication for intervention in 42.4% of patients. Five-year primary and primary-assisted patency rates stratified by TASC II classification were B: 55.1%, 91.9%; C: 37.4%, 74.6%; D: 35.5%, 67%, respectively (p = 0.23). Secondary patency based on TASC II classification was B: 92.9%, C: 83%, and D: 75.9%, respectively. Univariate analysis identified age > 75, CLI, and cerebrovascular disease as predictors for loss of patency. Reinterventions to maintain patency were required in 26.5% of TASC II B, 43.2% of TASC II C, and 25.6% of TASCII D lesions (p = NS) and mean time to reintervention ranged from 22 to 29 months with no significant difference related to TASC II classification. A total of eight limbs (3.38%) were converted to open revascularization with two (0.85%) having a change in their initial preoperatively identified bypass target site. Three limbs (1.27%) required a major amputation during follow-up. Survival at 5 years was 44.3%; CLI and smoking were identified as risk factors for death (hazard ratio [HR] 2.6, 1.75–3.84, p < 0.001, HR 3.33, 1.70–6.52, p < 0.001), respectively. Conclusion Long-term patency of endovascular interventions for complicated femoropopliteal lesions is acceptable across TASC II classification and is associated with excellent limb salvage. Mortality in this patient cohort is significant with CLI and smoking being identified as predictors of death.

Endovascular Therapy as the Primary Approach for Limb Salvage in Patients with Critical Limb Ischemia: Experience with 443 Infrapopliteal Procedures

Vascular ◽  
2006 ◽  
Vol 14 (2) ◽  
pp. 63-69 ◽  
Author(s):  
Marc Bosiers ◽  
Joseph P. Hart ◽  
Koen Deloose ◽  
Jurgen Verbist ◽  
Patrick Peeters
Keyword(s):  
Limb Salvage ◽  
Excimer Laser ◽  
Critical Limb Ischemia ◽  
Limb Ischemia ◽  
Primary Treatment ◽  
Transluminal Angioplasty ◽  
Primary Patency ◽  
Endovascular Intervention ◽  
Below The Knee ◽  
Surgical Data

Endovascular strategies for the treatment of critical infrageniculate peripheral arterial occlusive disease exist and are becoming the primary methodology for such lesions at many centers. Although technically feasible for experienced operators, the evidence to support this strategy for below the knee (BTK) interventions is still evolving. We studied the 6-month and 1-year outcomes of percutaneous transluminal angioplasty (PTA) alone, PTA with stenting, and excimer laser recanalization for BTK lesions in patients with critical limb ischemia. Between September 2002 and June 2005, 443 patients (355 Rutherford category 4, 82 category 5, 6 category 6) underwent intervention for 681 BTK lesions. Follow-up was performed at 6-month intervals after index intervention: limb salvage data were recorded and duplex ultrasonography was performed to measure the patency of treated areas. The primary patency and limb salvage rates of the entire population were 85.2% and 97.0% and 74.2% and 96.6% at 6 months and 1 year, respectively. Stratified for the treatment strategy (PTA alone in 79, PTA with stenting in 300 patients, and excimer laser in 64), 1-year primary patency rates were 68.6%, 75.5%, and 75.4%, whereas the limb salvage rates were 96.7%, 98.6%, and 87.9% for each modality, respectively. Endovascular intervention will become the primary treatment for BTK lesions in patients with critical limb ischemia, with 1-year primary patency and limb salvage rates that compare favorably with published surgical data. Prospective, randomized, multicenter trials will be needed to further establish the role of endovascular intervention in this challenging patient group.

scholarly journals Relationship between cell number and clinical outcomes of autologous bone-marrow mononuclear cell implantation in critical limb ischemia

2020 ◽  
Vol 10 (1) ◽  
Author(s):  
Farina Mohamad Yusoff ◽  
Masato Kajikawa ◽  
Yuji Takaeko ◽  
Shinji Kishimoto ◽  
Haruki Hashimoto ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Cell Therapy ◽  
Clinical Outcomes ◽  
Critical Limb Ischemia ◽  
Autologous Bone Marrow ◽  
Limb Ischemia ◽  
Major Amputation ◽  
Significant Difference ◽  
Autologous Bone ◽  
Death Group

AbstractCell therapy using intramuscular injections of autologous bone-marrow mononuclear cells (BM-MNCs) improves clinical symptoms and can prevent limb amputation in atherosclerotic peripheral arterial disease (PAD) patients with critical limb ischemia (CLI). The purpose of this study was to evaluate the effects of the number of implanted BM-MNCs on clinical outcomes in atherosclerotic PAD patients with CLI who underwent cell therapy. This study was a retrospective observational study with median follow-up period of 13.5 years (range, 6.8–15.5 years) from BM-MNC implantation procedure. The mean number of implanted cells was 1.2 ± 0.7 × 109 per limb. There was no significant difference in number of BM-MNCs implanted between the no major amputation group and major amputation group (1.1 ± 0.7 × 109 vs. 1.5 ± 0.8 × 109 per limb, P = 0.138). There was also no significant difference in number of BM-MNCs implanted between the no death group and death group (1.5 ± 0.9 × 109 vs. 1.8 ± 0.8 × 109 per patient, P = 0.404). Differences in the number of BM-MNCs (mean number, 1.2 ± 0.7 × 109 per limb) for cell therapy did not alter the major amputation-free survival rate or mortality rate in atherosclerotic PAD patients with CLI. A large number of BM-MNCs will not improve limb salvage outcome or mortality.

scholarly journals Procalcitonin Is a Prognostic Marker of Hospital Outcomes in Patients with Critical Limb Ischemia and Diabetic Foot Infection

2019 ◽  
Vol 2019 ◽  
pp. 1-5 ◽  
Author(s):  
Marco Meloni ◽  
Valentina Izzo ◽  
Laura Giurato ◽  
Enrico Brocco ◽  
Michele Ferrannini ◽  
...  
Keyword(s):  
Limb Salvage ◽  
Critical Limb Ischemia ◽  
Diabetic Foot ◽  
Univariate Analysis ◽  
Limb Ischemia ◽  
Major Amputation ◽  
Diabetic Patients ◽  
Hospital Outcomes ◽  
Diabetic Foot Infection ◽  
The Mean

Aim. To evaluate the prognostic role of procalcitonin (PCT) in patients with diabetic foot infection (DFI) and critical limb ischemia (CLI). Materials and Methods. The study group was composed of diabetic patients with DFI and CLI. All patients were treated according to a preset limb salvage protocol which includes revascularization, wound debridement, antibiotic therapy, and offloading. Inflammatory markers, including PCT, were evaluated at admission. Only positive values of PCT, greater than 0.5 ng/ml, were considered. Hospital outcomes were categorized as limb salvage (discharge with preserved limb), major amputation (amputation above the ankle), and mortality. Results. Eighty-six patients were included. The mean age was 67.3±11.4 years, 80.7% were male, 95.1% had type 2 diabetes, and the mean diabetes duration was 20.5±11.1 with a mean HbA1c of 67±16 mmol/mol. 66/86 (76.8%) of patients had limb salvage, 7/86 (8.1%) had major amputation, and 13/86 (15.1%) died. Patients with positive PCT baseline values in comparison to those with normal values showed a lower rate of limb salvage (30.4 versus 93.6%, p=0.0001), a higher rate of major amputation (13 versus 6.3%, p=0.3), and a higher rate of hospital mortality (56.5 versus 0%, p<0.0001). At the multivariate analysis of independent predictors found at univariate analysis, positive PCT was an independent predictor of major amputation [OR 3.3 (CI 95% 2.0-5.3), p=0.0001] and mortality [OR 4.1 (CI 95% 2.2-8.3), p<0.0001]. Discussion. Positive PCT at admission increased the risk of major amputation and mortality in hospital patients with DFI and CLI.

Digital Subtraction Angiography Prior to an Amputation for Critical Limb Ischemia (CLI): An Expert Recommendation Statement From the CLI Global Society to Optimize Limb Salvage

2020 ◽  
Vol 27 (4) ◽  
pp. 540-546 ◽  
Author(s):  
Jihad A. Mustapha ◽  
Fadi A. Saab ◽  
Brad J. Martinsen ◽  
Constantino S. Pena ◽  
Thomas Zeller ◽  
...  
Keyword(s):  
Digital Subtraction Angiography ◽  
Limb Salvage ◽  
Critical Limb Ischemia ◽  
Limb Ischemia ◽  
Digital Subtraction ◽  
Global Society ◽  
Expert Recommendation ◽  
Below The Knee ◽  
Artery Disease ◽  
Quality Imaging

Despite recent guideline updates on peripheral artery disease (PAD) and critical limb ischemia (CLI) treatment, the optimal treatment for CLI is still being debated. As a result, care is inconsistent, with many CLI patients undergoing an amputation prior to what many consider to be mandatory: consultation with an interdisciplinary specialty care team and a comprehensive imaging assessment. More importantly, quality imaging is critical in CLI patients with below-the-knee disease. Therefore, the CLI Global Society has put forth an interdisciplinary expert recommendation for superselective digital subtraction angiography (DSA) that includes the ankle and foot in properly indicated CLI patients to optimize limb salvage. A recommended imaging algorithm for CLI patients is included.

Evolution of Major Amputation Risk in Patients Hospitalized in France for Critical Limb Ischemia: The COPART Registry

Angiology ◽  
2020 ◽  
pp. 000331972097682
Author(s):  
Alice Coudene ◽  
Francois-Xavier Lapébie ◽  
Ileana Desormais ◽  
P Lacroix ◽  
Valerie Aurillac ◽  
...  
Keyword(s):  
Critical Limb Ischemia ◽  
Limb Ischemia ◽  
Arterial Disease ◽  
Major Amputation ◽  
The Past ◽  
Significant Difference ◽  
Before And After ◽  
Secondary Outcomes ◽  
Artery Disease ◽  
Peripheral Arterial

Over the past decade, improvements in medical treatment and revascularization techniques have been beneficial for patients with peripheral artery disease in the late stage of critical limb ischemia (CLI). We evaluated the putative reduction in the number of major amputees in the Cohorte des Patients ARTeriopathes (COPART) cohort over time. Patients were selected from this multicenter cohort, from 2006 to 2016, for CLI according to Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease II criteria. Patients included before and after 2011 were compared. Patients were followed for 1 year. Primary outcome was the rate of major amputations. Secondary outcomes were minor amputations, deaths from all causes, cardiovascular deaths; 989 patients were included, 489 before 2011 and 450 after 2011. There was a significant decrease in rates of major amputation after 2011 (17% vs 25%), confirmed in multivariate analysis (odds ratio [OR]: 1.5 [1.1-2.2]), an increase in revascularization, particularly distal angioplasty (OR: 2.7 [1.7-4.4]) and increased statin intake (OR: 1.6 [1.1-2.1]). For secondary outcomes, there was no significant difference. Limb prognosis of CLI patients has improved over the past decade, possibly due to more revascularizations, particularly distal ones, and increased statin use.

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