scholarly journals Non-compressible ABIs are associated with an increased risk of major amputation and major adverse cardiovascular events in patients with critical limb ischemia

2017 ◽  
Vol 22 (3) ◽  
pp. 210-217 ◽  
Author(s):  
Gagan D Singh ◽  
Ehrin J Armstrong ◽  
Stephen W Waldo ◽  
Bejan Alvandi ◽  
Ellen Brinza ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Critical Limb Ischemia ◽  
Cardiovascular Events ◽  
Limb Ischemia ◽  
Major Amputation ◽  
Tissue Loss ◽  
Major Adverse Cardiovascular Events ◽  
Increased Risk ◽  
Artery Disease ◽  
Stage Renal Disease

Ankle–brachial indices (ABIs) are important for the assessment of disease burden among patients with peripheral artery disease. Although low values have been associated with adverse clinical outcomes, the association between non-compressible ABI (ncABI) and clinical outcome has not been evaluated among patients with critical limb ischemia (CLI). The present study sought to compare the clinical characteristics, angiographic findings and clinical outcomes of those with compressible (cABI) and ncABI among patients with CLI. Consecutive patients undergoing endovascular evaluation for CLI between 2006 and 2013 were included in a single center cohort. Major adverse cardiovascular events (MACE) were then compared between the two groups. Among 284 patients with CLI, 68 (24%) had ncABIs. These patients were more likely to have coronary artery disease ( p=0.003), diabetes ( p<0.001), end-stage renal disease ( p<0.001) and tissue loss ( p=0.01) when compared to patients with cABI. Rates of infrapopliteal disease were similar between the two groups ( p=0.10), though patients with ncABI had lower rates of iliac ( p=0.004) or femoropopliteal stenosis ( p=0.003). Infrapopliteal vessels had smaller diameters ( p=0.01) with longer lesions ( p=0.05) among patients with ncABIs. After 3 years of follow-up, ncABIs were associated with increased rates of mortality (HR 1.75, 95% CI: 1.12–2.78), MACE (HR 2.04, 95% CI: 1.35–3.03) and major amputation (HR 1.96, 95% CI: 1.11–3.45) when compared to patients with cABIs. In conclusion, ncABIs are associated with higher rates of mortality and adverse events among those undergoing endovascular therapy for CLI.

scholarly journals Gender-related variation in the clinical presentation and outcomes of critical limb ischemia

2013 ◽  
Vol 18 (1) ◽  
pp. 19-26 ◽  
Author(s):  
Caroline E McCoach ◽  
Ehrin J Armstrong ◽  
Satinder Singh ◽  
Usman Javed ◽  
David Anderson ◽  
...  
Keyword(s):  
Limb Salvage ◽  
Critical Limb Ischemia ◽  
Cardiovascular Events ◽  
Limb Ischemia ◽  
Patient Characteristics ◽  
Percutaneous Intervention ◽  
Major Adverse Cardiovascular Events ◽  
Kaplan Meier ◽  
Multi Level ◽  
Artery Disease

Critical limb ischemia (CLI) is a major cause of limb loss and mortality among patients with advanced peripheral artery disease. Our objective was to evaluate the gender-specific differences in patient characteristics and clinical outcomes among patients with CLI. We performed a retrospective analysis of 97 women and 122 men presenting with CLI who underwent angiography from 2006 to 2010. Baseline demographics, procedural details, and lesion characteristics were assessed for each patient. Kaplan–Meier analysis was used to assess long-term patient and lesion-level outcomes. Cox proportional hazard modeling was used to evaluate the relationship between gender and major adverse cardiovascular events (MACE). Compared to men, women were less likely to have a history of coronary artery disease (39% vs 54%, p = 0.02) or diabetes (57% vs 70%, p = 0.05) but had similar baseline medical therapy. At angiography, women were more likely to have significant femoropopliteal (77% vs 67%, p = 0.02) and multi-level infrainguinal disease (63% vs 51%, p = 0.02). Women were also more likely to undergo multi-vessel percutaneous intervention (69% vs 55%, p = 0.05), but had similar rates of limb salvage after percutaneous intervention or surgical bypass (HR 0.94 [95% CI 0.45–1.94], p = 0.9). During follow-up, women had higher rates of subsequent major adverse cardiovascular events (HR 1.63 [95% CI 1.01–2.63], p = 0.04). In conclusion, women with CLI are more likely to present with femoropopliteal and multi-level infrainguinal disease. Despite similar rates of limb salvage, women with CLI have an increased rate of subsequent major adverse cardiovascular events.

Contemporary Medical Management of Peripheral Artery Disease

2021 ◽  
Vol 128 (12) ◽  
pp. 1868-1884
Author(s):  
Marc P. Bonaca ◽  
Naomi M. Hamburg ◽  
Mark A. Creager
Keyword(s):  
Lower Extremity ◽  
Peripheral Artery Disease ◽  
Critical Limb Ischemia ◽  
Cardiovascular Events ◽  
Limb Ischemia ◽  
Major Adverse Cardiovascular Events ◽  
Peripheral Artery ◽  
Walking Capacity ◽  
Medical Therapies ◽  
Artery Disease

Peripheral artery disease (PAD) is a manifestation of systemic atherosclerosis. Modifiable risk factors including cigarette smoking, dyslipidemia, diabetes, poor diet quality, obesity, and physical inactivity, along with underlying genetic factors contribute to lower extremity atherosclerosis. Patients with PAD often have coexistent coronary or cerebrovascular disease, and increased likelihood of major adverse cardiovascular events, including myocardial infarction, stroke and cardiovascular death. Patients with PAD often have reduced walking capacity and are at risk of acute and chronic critical limb ischemia leading to major adverse limb events, such as peripheral revascularization or amputation. The presence of polyvascular disease identifies the highest risk patient group for major adverse cardiovascular events, and patients with prior critical limb ischemia, prior lower extremity revascularization, or amputation have a heightened risk of major adverse limb events. Medical therapies have demonstrated efficacy in reducing the risk of major adverse cardiovascular events and major adverse limb events, and improving function in patients with PAD by modulating key disease determining pathways including inflammation, vascular dysfunction, and metabolic disturbances. Treatment with guideline-recommended therapies, including smoking cessation, lipid lowering drugs, optimal glucose control, and antithrombotic medications lowers the incidence of major adverse cardiovascular events and major adverse limb events. Exercise training and cilostazol improve walking capacity. The heterogeneity of risk profile in patients with PAD supports a personalized approach, with consideration of treatment intensification in those at high risk of adverse events. This review highlights the medical therapies currently available to improve outcomes in patients with PAD.

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 One-Year Results of the LIBERTY 360 Study: Evaluation of Acute and Midterm Clinical Outcomes of Peripheral Endovascular Device Interventions

2019 ◽  
Vol 26 (2) ◽  
pp. 143-154 ◽  
Author(s):  
Jihad Mustapha ◽  
William Gray ◽  
Brad J. Martinsen ◽  
Ryan W. Bolduan ◽  
George L. Adams ◽  
...  
Keyword(s):  
Multicenter Study ◽  
Treatment Strategies ◽  
Limb Ischemia ◽  
Major Amputation ◽  
Tissue Loss ◽  
Routine Practice ◽  
Target Vessel Revascularization ◽  
Kaplan Meier ◽  
Artery Disease ◽  
Endovascular Device

Purpose: To report the 1-year results of a multicenter study of peripheral artery disease (PAD) treatment with a variety of endovascular treatment strategies employed in routine practice. Materials and Methods: The LIBERTY trial ( ClinicalTrials.gov identifier NCT01855412) is a prospective, observational, core laboratory–assessed, multicenter study of endovascular device intervention in 1204 subjects (mean age 69.8±10.7 years; 770 men) stratified by Rutherford category (RC): claudicants (RC2,3; n=501) and critical limb ischemia (CLI) with no/minimal tissue loss (RC4,5; n=603) or significant tissue loss (RC6; n=100). Key outcomes included quality of life (QoL) measures (VascuQol and EuroQol) and freedom from major adverse events (MAE), defined as death (within 30 days), major amputation, and target vessel revascularization based on Kaplan-Meier analysis. Results: Successful revascularization was beneficial, with RC improvement noted across all groups. Thirty-day freedom from MAE estimates were high across all groups: 99.2% in RC2,3, 96.1% in RC4,5, and 90.8% in RC6. At 12 months, the freedom from MAE was 82.6% in RC2,3, 73.2% in RC4,5, and 59.3% in RC6 patients. Estimates for freedom from major amputation at 12 months were 99.3%, 96.0%, and 81.7%, respectively. QoL scores improved significantly across all domains in all groups with 12-month VascuQol total scores of 5.3, 5.0, and 4.8 for RC2,3, RC4,5, and RC6, respectively. Conclusion: The results indicate that peripheral endovascular intervention is a viable treatment option for RC2,3, RC4,5, and RC6 patients as evidenced by the high freedom from major amputation, as well as the improvement in QoL and the RC at 12 months. Furthermore, primary unplanned amputation is often not necessary in RC6.

Balloon Angioplasty in Chronic Critical Limb Ischemia: Factors Affecting Clinical and Angiographic Outcome

2002 ◽  
Vol 9 (4) ◽  
pp. 403-410 ◽  
Author(s):  
Hannes Balmer ◽  
Felix Mahler ◽  
Dai-Do Do ◽  
Jürgen Triller ◽  
Iris Baumgartner
Keyword(s):  
Balloon Angioplasty ◽  
Critical Limb Ischemia ◽  
Duplex Ultrasound ◽  
Limb Ischemia ◽  
Target Lesion ◽  
Major Amputation ◽  
Factors Affecting ◽  
Chronic Critical Limb Ischemia ◽  
Endpoint Event ◽  
Artery Disease

Purpose: To assess factors that affect clinical and angiographic outcome in chronic critical limb ischemia (CLI) 12 months after primary, technically successful balloon angioplasty (BA) in infrainguinal arteries. Methods: Sixty consecutive patients (37 women; mean age 75 ± 10 years, range 53–99) with technically successful BA in 66 limbs were followed for 12 months or until death, for major amputation, or repeat target lesion revascularization (TLR). Assessment at baseline and 1 day and 12 months after BA or at an endpoint event, if feasible, was performed with angiography or duplex ultrasound (above-knee revascularization only). Mortality, limb prognosis, and restenosis rate were correlated with cardiovascular risk factors, hemodynamic measures, and angiographic features. Results: Mortality was 25% at 1 year; compared to survivors, nonsurvivors more often had coronary artery disease (93% versus 44% for survivors, p<0.001), bilateral CLI (60% versus 29%, p=0.033), and higher fibrinogen levels (5.1 g/L versus 4.3 g/L, p=0.049). CLI resolved in more than half (35, 53%) of the limbs without repeat TLR. The major amputation rate was 6%. Limb prognosis correlated with ankle pressures after BA. Restenosis rates were 65% at the femoropopliteal and 56% at the infrapopliteal level (NS); these correlated with the length of the treated arterial segment (8.7 cm with restenosis versus 4.0 cm without, p<0.001). Conclusions: High mortality in CLI was associated with an extensive, clinically manifest arteriosclerotic process and high fibrinogen levels. Limb prognosis and restenosis after BA were primarily influenced by local hemodynamic and technical factors. Despite considerable restenosis, more than 90% of survivors avoided major amputations.

scholarly journals Neutrophil-to-lymphocyte ratio associated with an increased risk of mortality in patients with critical limb ischemia

PLoS ONE ◽  
2021 ◽  
Vol 16 (5) ◽  
pp. e0252030
Author(s):  
Min-I. Su ◽  
Cheng-Wei Liu
Keyword(s):  
Hospital Mortality ◽  
Critical Limb Ischemia ◽  
Limb Ischemia ◽  
Neutrophil To Lymphocyte Ratio ◽  
Major Adverse Cardiovascular Events ◽  
Acute Limb Ischemia ◽  
Male Body ◽  
Lymphocyte Ratio ◽  
Increased Risk ◽  
Related Mortality

Purpose Association of the neutrophil-to-lymphocyte ratio (NLR) with mortality has not been comprehensively explored in critical limb ischemia (CLI) patients. We investigated the association between the NLR and clinical outcomes in CLI. Materials and methods We retrospectively enrolled consecutive CLI patients between 1/1/2013 and 12/31/2018. Receiver operating characteristic curve analysis determined NLR cutoffs for 1-year in-hospital, all-cause and cardiac-related mortality; major adverse cardiovascular events (MACEs); and major adverse limb events (MALEs). Results Among 195 patients (age, 74.0 years, SD: 11.5; 51.8% male; body mass index, 23.4 kg/m2, SD: 4.2), 14.4% exhibited acute limb ischemia. After 1 year, patients with NLR>8 had higher in-hospital mortality (21.1% vs. 3.6%, P<0.001), all-cause mortality (54.4% vs. 13.8%, P<0.001), cardiac-related mortality (28.1% vs. 6.5%, P<0.001), MACE (29.8% vs. 13.0%, P = 0.008), and MALE (28.1% vs. 13.0%, P = 0.021) rates than those with NLR<8. In multivariate logistic regression, NLR≥8 was significantly associated with all-cause (P<0.001) and cardiac-related (adjusted HR: 5.286, 95% CI: 2.075–13.47, P<0.001) mortality, and NLR≥6 was significantly associated with MALEs (adjusted HR: 2.804, 95% CI: 1.292–6.088, P = 0.009). Each increase in the NLR was associated with increases in all-cause (adjusted HR: 1.028, 95% CI: 1.008–1.049, P = 0.007) and cardiac-related (adjusted HR:1.027, 95% CI: 0.998–1.057, P = 0.073) mortality but not in-hospital mortality or MACEs. Conclusion CLI patients with high NLRs had significantly higher risks of 1-year all-cause and cardiac-related mortality and MALEs. The NLR can be used for prognostic prediction in these patients.

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.

Abstract 13234: The Association Between Serum Potassium and Major Adverse Cardiovascular Events in Patients With Chronic Kidney Disease

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Alex Yang ◽  
Jiacong Luo ◽  
Donna E Jensen ◽  
Steven M Brunelli
Keyword(s):  
Kidney Disease ◽  
Serum Potassium ◽  
Cardiovascular Events ◽  
Beta Blockers ◽  
High Serum ◽  
Major Adverse Cardiovascular Events ◽  
Channel Blockers ◽  
Increased Risk ◽  
Rate Ratios ◽  
Stage Renal Disease

Introduction: Patients with kidney disease often have high serum potassium (K) due to diminished excretory capacity. Hypothesis: We evaluated the association of high K with rates of arrhythmia and major adverse cardiovascular events (MACE; composite of myocardial infarction, stroke, heart failure, and arrhythmia). Methods: We studied a retrospective cohort of patients with eGFR <60 mL/min/1.73m 2 between Jan-2009 and Jun-2013 (N=55,266). Patients were followed until the end of study (30-Jun-2013), death, end-stage renal disease, or transfer of care. Serum K, eGFR, and 13 covariates including demographics, prevalent comorbidities, and medication use (beta blockers, centrally acting calcium channel blockers, and loop and thiazide diuretics) were considered on a time-varying basis, updated for each K measurement. Results: At baseline, 15%, 4%, and 1% of patients had serum K 5.0-5.4, 5.5-5.9, and ≥6.0 mEq/L, respectively. Prevalence was greater in lower eGFR strata. Within each eGFR stratum serum K demonstrated U-shaped associations with rates of MACE and arrhythmia, displayed for eGFR <30 mL/min/1.73m 2 . Compared to K 4.5-4.9 mEq/L, incidence rate ratios (IRRs) of MACE for K ≥6.0 mEq/L were 2.11 [95%CI, 1.68-2.65], 1.44 [1.12-1.84], 1.56 [1.11-2.17], and 2.11 [1.53-2.89] in the eGFR <30, 30-39, 40-49, and 50-59 strata, respectively. K ≥6.0 mEq/L was associated with increased rate of arrhythmia in the lowest eGFR stratum (Figure); point estimates in other eGFR strata ranged from 1.39 to 1.53, but were not significant. Conclusions: K ≥6.0 mEq/L is associated with increased risk of MACE among patients with eGFR <60 mL/min/1.73m 2 and with arrhythmia among patients with eGFR <30 mL/min/1.73m 2 . Renal impairment should be considered when determining serum K targets with respect to cardiovascular risk.

Combination Use of Clopidogrel and Proton Pump Inhibitors Increases Major Adverse Cardiovascular Events in Patients With Coronary Artery Disease

2016 ◽  
Vol 22 (2) ◽  
pp. 142-152 ◽  
Author(s):  
Qiang Niu ◽  
Zhongsu Wang ◽  
Yong Zhang ◽  
Jiangrong Wang ◽  
Pei Zhang ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Coronary Artery ◽  
Combination Therapy ◽  
Proton Pump Inhibitors ◽  
Proton Pump ◽  
Cardiovascular Events ◽  
Cochrane Library ◽  
Major Adverse Cardiovascular Events ◽  
Increased Risk ◽  
Artery Disease

Background: Published data indicated that combination use of clopidogrel and proton pump inhibitors (PPIs) may increase the incidence of major adverse cardiovascular events (MACEs). This has been a highly controversial topic for years. Design: The present study was performed to evaluate whether combination therapy of clopidogrel and PPIs is associated with increased risk of MACEs than with clopidogrel alone in patients with coronary artery disease. Methods: A systematic search of MEDLINE, EMBASE, and the Cochrane Library was conducted for studies recording the occurrence of MACEs in patients with exposure to concomitant use of clopidogrel and PPIs up to February 2015. Odds ratios (ORs) were combined using a random-effects model. Results: Patients receiving combination therapy with PPIs and clopidogrel were at significantly increased risk of MACEs (OR: 1.42; 95% confidence interval [CI]: 1.30-1.55). Adding a PPI to clopidogrel treatment was associated with a higher rate of MACE occurrence in rapid metabolizers (RMs, *1/*1) of CYP2C19 (OR: 1.42; 95% CI: 1.12-1.81), but there was no obviously increased rate (OR: 1.43; 95% CI: 0.89-2.28) in decreased metabolizers (with 1 or 2 loss-of-function allele). The increased risk of MACEs was similar in 4 classes of PPIs (omeprazole, lansoprazole, esomeprazole, and pantoprazole), but rabeprazole (OR: 1.03; 95% CI: 0.55-1.95) wasn’t. Conclusion: The combination use of clopidogrel and certain types of PPIs (omeprazole, lansoprazole, esomeprazole, pantoprazole) increases the risk of MACE in patients with coronary artery disease. Only in the RMs of CYP2C19, PPIs were associated with significantly increased MACE in patients coadministered with clopidogrel.

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