Journal articles: 'Critical limb threatening ischemia'

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Suresh, KalkunteR. "What Ails Diagnosis of Peripheral Arterial Disease/Critical Limb Ischemia/Critical Limb-threatening Ischemia in India?" Indian Journal of Vascular and Endovascular Surgery 4, no. 4 (2017): 139. http://dx.doi.org/10.4103/ijves.ijves_59_17.

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Azab, Sandi, Philip Britz-McKibbin, Abdelrahman Zamzam, Rawand Abdin, and Mohammad Qadura. "Serum Metabolomic Profile of Critical Limb-Threatening Ischemia Patients." Journal of Vascular Surgery 72, no. 1 (July 2020): e214. http://dx.doi.org/10.1016/j.jvs.2020.04.362.

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Chandra, Ankur, and Niren Angle. "Occluded Infrainguinal Bypass Graft: Potential Source of Limb-Threatening Emboli." Vascular 14, no. 3 (May 1, 2006): 156–60. http://dx.doi.org/10.2310/6670.2006.00029.

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Surgical bypass represents one of the chief treatment modalities for peripheral arterial occlusive disease. Despite improving techniques, graft occlusion accounts for the majority of these bypass failures. Once occluded, however, these grafts are thought to rarely pose a threat for future ischemic events. This report describes two patients with previously thrombosed grafts who subsequently presented with limb-threatening ischemia owing to peripheral embolization from the graft. Two patients with occluded grafts presented with ipsilateral limb-threatening acute ischemia. Both of these patients developed severe acute limb-threatening ischemia weeks to months after known graft thrombosis. Arteriography revealed peripheral embolization in each case. Both patients were operated on for disconnection of the thrombosed graft from the native circulation and have been free of recurrent symptoms. The occluded graft, although generally innocuous, can be a source of peripheral emboli, resulting in peripheral embolization and acute limb ischemia. Both patients in this report developed limb-threatening ischemia owing to embolization from the cul-de-sac of occluded prosthetic grafts. Due to the rarity of the condition and its associated morbidity and mortality, awareness and recognition of this phenomenon are critical. Operative disconnection is recommended if the embolism occurs downstream of the graft and no other embolic source can be identified.

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krisnasari, Imelda, Novi Kurnianingsih, Mohammad Saifur Rohman, and Budi Satrijo. "Limb Preservation with Balloon Angioplasty in Critical Limb Threatening Ischemia: A Case Report." Heart Science Journal 2, no. 2 (April 1, 2021): 25–30. http://dx.doi.org/10.21776/ub.hsj.2021.002.02.6.

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Introduction: Chronic limb-threatening ischemia (CLTI) is a syndrome that represents the end-stage of peripheral artery disease (PAD) that increased the risk of major amputation and cardiovascular events. The initial treatment for CLTI may significantly impact the risk of major amputation or death. Objective: This case report aims to describe limb preservation with balloon angioplasty in a Critical Limb Ischemia patient. Case Presentation: A hypertensive 72-years old female complained of left leg pain followed by a wound on her left toe four months ago. Her toe was amputated, but the wound persists. On physical examination, the pulsation was diminished in her left foot. Duplex ultrasound showed monophasic spectral doppler from left popliteal artery to distal left anterior tibial artery (ATA) and distal posterior tibial artery (PTA). CT-Angiography showed short total occlusion (2cm) at the distal left Superficial Femoral artery (SFA), multiple stenoses with maximal 90% stenosis at the left ATA, and chronic total occlusion at the proximal-mid left posterior tibial artery (PTA). She was diagnosed with CLTI left inferior extremity Fontaine IV Rutherford 5. The angiography result was similar to the CT-angiography result. The patient was successfully treated with plain balloon angioplasty from distal left SFA to distal left ATA and drug-coated balloon angioplasty from the distal left SFA to the popliteal artery. Her wound was also consulted to the surgical department. Conclusion: Appropriate revascularization is fundamental to limb preservation. We successfully perform endovas- cular strategy with TIMI flow 3 from left SFA to distal left ATA and distal PTA in our patient, but we still need further holistic CLTI management.

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Silva, J. "Mechanical Thrombectomy in the Treatment of Acute Critical Limb Threatening Ischemia." Journal of the American College of Cardiology 31, no. 2 (February 1998): 521A. http://dx.doi.org/10.1016/s0735-1097(97)88271-x.

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Silva, J. A., E. Ramee, S. Y. Zhang, T. J. Collins, J. S. Jenkins, C. J. White, and S. R. Ramee. "Mechanical thrombectomy in the treatment of acute critical limb threatening ischemia." Journal of the American College of Cardiology 31 (February 1998): 521. http://dx.doi.org/10.1016/s0735-1097(98)80622-0.

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Dhillon, Ashwat S., Jorge Caro, Han Tun, David G. Armstrong, Vincent Rowe, David M. Shavelle, and Leonardo C. Clavijo. "Therapeutic Window of Clopidogrel and Ticagrelor in Patients With Critical Limb-Threatening Ischemia." Journal of Cardiovascular Pharmacology and Therapeutics 25, no. 2 (September 24, 2019): 158–63. http://dx.doi.org/10.1177/1074248419877411.

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Background: Critical limb-threatening ischemia (CLTI) is associated with an increased risk of major adverse limb events and mortality. High on-treatment platelet reactivity (HPR) is associated with an increased risk of ischemic events, while low on-treatment platelet reactivity (LPR) is associated with an increased risk of bleeding. This study investigates the frequency with which patients with CLTI on clopidogrel or ticagrelor achieve a “therapeutic window” (TW) of platelet inhibition. Methods: Data from the “Switch To Ticagrelor in Critical Limb Ischemia Anti-Platelet Study” were assessed retrospectively to determine the incidence of TW of on-treatment platelet reactivity in 50 consecutive patients with CLTI (mean age: 65.2 ± 10.5 years, 54% male). The data included 4 measurements of patients’ platelet reactivity using the VerifyNow P2Y12 Assay: baseline and steady state platelet reactivity on clopidogrel 75 mg daily and on ticagrelor 90 mg twice daily. Results: At baseline, 46% of patients on clopidogrel were within TW of on-treatment platelet reactivity compared to 10% of patients on ticagrelor ( P < .0001). At steady state, 42% of patients on clopidogrel were within the TW compared to 10% of patients on ticagrelor ( P < .0001). Patients on ticagrelor exhibited higher rates of LPR compared to those on clopidogrel at baseline as well as at steady state (baseline 88% vs 18%, steady state 88% vs 28%; P < .0001). Conclusion: Although ticagrelor has been proposed as an alternative for patients with HPR on clopidogrel, the current study observes an excess of platelet inhibition with ticagrelor in most patients with CLTI at a dose of 90 mg twice daily.

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Hage, Anthony, Joseph McDevitt, Jeffrey Chick, and Venu Vadlamudi. "Acute Limb Ischemia Therapies: When and How to Treat Endovascularly." Seminars in Interventional Radiology 35, no. 05 (December 2018): 453–60. http://dx.doi.org/10.1055/s-0038-1676321.

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AbstractAcute limb ischemia is an emergent limb and life-threatening condition with high morbidity and mortality. An understanding of the presentation, clinical evaluation, and initial workup, including noninvasive imaging evaluation, is critical to determine an appropriate management strategy. Modern series have shown endovascular revascularization for acute limb ischemia to be safe and effective with success rates approaching surgical series and with similar, or even decreased, perioperative morbidity and mortality. A thorough understanding of endovascular techniques, associated pharmacology, and perioperative care is paramount to the endovascular management of patients presenting with acute limb ischemia. This article discusses the diagnosis and strategies for endovascular treatment of acute limb ischemia.

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Amann, Lüdemann, Rückert, Lawall, Liesenfeld, Schneider, and Schmidt-Lucke. "Design and rationale of a randomized, double-blind, placebo-controlled phase III study for autologous bone marrow cell transplantation in critical limb ischemia: the BONe Marrow Outcomes Trial in Critical Limb Ischemia (BONMOT-CLI)." Vasa 37, no. 4 (November 1, 2008): 319–25. http://dx.doi.org/10.1024/0301-1526.37.4.319.

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Background: Critical limb ischemia (CLI) is the end-stage of peripheral artery disease. Only about two thirds of patients with CLI can be revascularised, one third progresses to leg amputation with high associated morbidity and mortality. Therapeutic angiogenesis with bone marrow cells has shown promising improvement in less severe stages of peripheral ischemia. Our study evaluates the therapeutic value of bone marrow cell induced angiogenesis and arteriogenesis in severe, limb-threatening ischemia. Patients and methods: the BONe Marrow Outcome Trial in Critical Limb Ischemia (BONMOT-CLI) is a investigator-initiated, double-blinded, 1:1 randomized, placebo-controlled multi-centre study at 4 sites in Germany. Only patients with no option for revascularisation or after failed revascularisation will be included. A total of 90 patients is to be included. One arm with 45 subjects will be treated with a concentrate of autologous bone marrow cells which will be injected at 40 sites into the ischemic limb. In the placebo arm, study subjects will undergo a sham bone marrow punction and 40 saline injections. At three months, a combined primary endpoint of major amputation or persisting critical limb ischemia (no clinical or perfusion improvement) will be evaluated. Secondary endpoints are death, changes in perfusion, quality of life, walking distance, minor amputations, wound healing, collateral density and cancer incidence. Post-study follow-up is up to two years. Conclusions: The results of this first randomized placebo-controlled trial for autologous bone marrow cell therapy in CLI will clarify the value of this new therapeutic modality in a patient population with no other alternatives except major amputation.

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Armstrong, Ehrin J., Syed Alam, Steve Henao, Arthur C. Lee, Brian G. DeRubertis, Miguel Montero-Baker, Carlos Mena, et al. "Multidisciplinary Care for Critical Limb Ischemia: Current Gaps and Opportunities for Improvement." Journal of Endovascular Therapy 26, no. 2 (February 1, 2019): 199–212. http://dx.doi.org/10.1177/1526602819826593.

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Critical limb ischemia (CLI), defined as ischemic rest pain or nonhealing ulceration due to arterial insufficiency, represents the most severe and limb-threatening manifestation of peripheral artery disease. A major challenge in the optimal treatment of CLI is that multiple specialties participate in the care of this complex patient population. As a result, the care of patients with CLI is often fragmented, and multidisciplinary societal guidelines have not focused specifically on the care of patients with CLI. Furthermore, multidisciplinary care has the potential to improve patient outcomes, as no single medical specialty addresses all the facets of care necessary to reduce cardiovascular and limb-related morbidity in this complex patient population. This review identifies current gaps in the multidisciplinary care of patients with CLI, with a goal toward increasing disease recognition and timely referral, defining important components of CLI treatment teams, establishing options for revascularization strategies, and identifying best practices for wound care post-revascularization.

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Vavilov, V. N., A. Yu Zaritskey, D. G. Polyntsev, P. S. Kurianov, A. N. Krutikov, H. A. Zenkova, and F. Z. Shiritova. "Efficiency of mesenchymal stromal cells (MSCs) in the treatment of patients with critical limb-threatening ischemia." Regional blood circulation and microcirculation 20, no. 1 (March 22, 2021): 41–49. http://dx.doi.org/10.24884/1682-6655-2021-20-1-41-49.

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Relevance. The relevance of the study is determined by the fact that hopes are placed in the cell therapy for patients with critical limb-threatening (CLI) ischemia as a method of the restoration of blood circulation in the affected limb in patients who cannot undergo surgical or endovascular intervention. Aim. To evaluate the efficiency of allogeneic MSCs for the treatment of critical lower limb ischemia (randomized placebo-controlled study).Materials and methods. The study included 34 patients with critical lower limb ischemia (grade 4 according to Pokrovsky). There were 18 patients in the MSC group, and 16 patients in the placebo group). The groups were comparable concerning age, disease duration, and comorbidities. Allogeneic MSCs (phenotype CD73+, CD90+, CD105+, CD45–, CD34–, CD14–) were injected into the posterior calf muscles. Clinical outcome, ankle pressure, transcutaneous oxygen tension (tcpO2), and pain-free walking distance (PFWD) were evaluated. The patients were followed-up for 12–36 months. According to the clinical outcome in each group, the patients were divided into subgroups with «effect (+)» or «effect (–)». In 2 patients, there was an «uncertain clinical outcome». When analyzing the results, these patients were assigned to one or another subgroup.Results. In the MSC and placebo groups, the clinical outcome assessed as «effect (+)» or «effect (–)» did not differ (OR 1.5; 95 % CI 0.34–6.7). With different variants of group formation and with the assignment of patients with an «uncertain clinical outcome» to a one or another subgroup, the final results neither differed. According to instrumental research methods (PFWD, tcpO2, ankle pressure, angiography), there were no differences in the MSC and placebo groups. Conclusion. With different variants of analysis and group formation, no convincing evidence that allogeneic MSCs can be effective for the treatment of critical lower limb ischemia have been obtained.

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Botti, Charles F., Gary M. Ansel, Mitchell J. Silver, Billie J. Barker, and Sheila South. "Percutaneous Retrograde Tibial Access in Limb Salvage." Journal of Endovascular Therapy 10, no. 3 (June 2003): 614–18. http://dx.doi.org/10.1177/152660280301000330.

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Purpose: To describe a novel technique for percutaneous retrograde access of the tibial vessels after antegrade access failure in patients with chronic limb-threatening ischemia. Methods: Six patients who had failed antegrade access to infrapopliteal occlusions had attempted retrograde tibial puncture and wire passage into the proximally patent vessel. Endovascular intervention was carried out utilizing standard techniques. The patients were followed for functional class and wound healing. Results: All six patients were successfully recanalized. Five patients experienced rapid and dramatic healing of wounds that had previously been refractory to conservative therapy. The other patient did not experience healing and ultimately died of progressive intractable congestive heart failure in the setting of a severe ischemic cardiomyopathy. Conclusions: Retrograde tibial access can be a valuable technique in the armamentarium of a peripheral interventionist treating patients with chronic critical limb ischemia.

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Cheun, Tracy, Lalithapriya Jayakumar, Maureen Sheehan, Matthew Sideman, Lori Pounds, and Mark G. Davies. "VESS03. Outcomes of Isolated Inframalleolar (Pedal Artery) Interventions for Limb-Threatening Critical Ischemia." Journal of Vascular Surgery 67, no. 6 (June 2018): e49-e50. http://dx.doi.org/10.1016/j.jvs.2018.03.015.

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Saldana-Ruiz, Nallely, Gregory A. Magee, Kenneth R. Ziegler, Sukgu M. Han, Fred A. Weaver, and Vincent L. Rowe. "IP231. Persistence of Racial Disparities in Critical Limb-Threatening Ischemia Despite Medical Optimization." Journal of Vascular Surgery 69, no. 6 (June 2019): e172-e173. http://dx.doi.org/10.1016/j.jvs.2019.04.239.

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Cheun, Tracy J., and Mark G. Davies. "Influence of Heel Ulceration on Limb Salvage After Open and Endovascular Intervention for Limb-Threatening Critical Ischemia." Journal of Vascular Surgery 68, no. 2 (August 2018): e21. http://dx.doi.org/10.1016/j.jvs.2018.05.073.

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Martini, Romeo. "Current opinion on the role of the foot perfusion in limb amputation risk assessment." Clinical Hemorheology and Microcirculation 76, no. 3 (December 22, 2020): 405–12. http://dx.doi.org/10.3233/ch-200901.

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The most important and consulted guidelines dealing with not healing foot ulcers suggest the measurement of the foot perfusion (FP) to exclude the critical limb ischemia (CLI), because of the high risk of limb amputation. But the recommended cut-off values of FP fail to include all the heterogeneity of patients of the real-life with a not healing ulcer. Often these patients are diabetics with a moderate PAD but with a high level of infection. To meet this goal, in 2014, the Society for Vascular Surgery has published the “Lower Extremity Threatened Limb Classification System: Risk stratification based on Wound, Infection, and foot Ischemia (WIfI).” This new classification system has changed the criteria of assessment of limb amputation risk, replacing the single cut-off value role with a combination of a spectrum of perfusion values along with graded infection and dimension levels of skin ulcers. The impact of this new classification system was remarkable so to propose the substitution of the CLI definition, with the new Critical limb-threatening ischemia (CLTI), that seems to define the limb amputation risk more realistically

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Khokhlova, I. M., V. B. Kozhevnikov, K. N. Movchan, B. S. Artyushin, E. V. Bartashevich, A. V. Zharkov, and E. V. Zheleznyi. "Organizational problems and possible ways of its resolve when providing emergency surgical care to patients with comorbid status in a highly specialized medical institution." Research and Practical Medicine Journal 7, no. 2 (June 25, 2020): 64–74. http://dx.doi.org/10.17709/2409-2231-2020-7-2-6.

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Purpose of the study. To demonstrate the difficulties of objective interpretation of providing medical care to patients with critical limb ischemia.Materials and methods. The results of treatment of more than 29 thousand patients of one of the highly specialized medical organizations of St. Petersburg were studied, in which the main activity of the staff is the examination of patients with surgical infection of soft tissues (particularly, the critical limb ischemia).Results. It has been ascertained that, despite the unconditional success of providing medical care to patients with critical limb ischemia, a high frequency of unsatisfactory treatment results for this category of patients remains (in 2017, among 685 patients of the specialized department of the highly specialized medical organization, the proportion of cases of performing high amputations of limbs and mortality, respectively, was 11,7% (80) and 2,6% (18)). It has been demonstrated on clinical examples that the pronounced comorbidity of critical limb ischemia patients and the severity of their general condition (combined with organizational difficulties in providing them with providing medical care in conditions of highly specialized medical organization) contribute to the formation of complications (up to lethal outcomes) of not only the underlying, but also concomitant diseases. Difficulties in providing medical care of adequate quality in life-threatening conditions for patients of highly specialized medical organization in cases of critical limb ischemia necessitate a wider interaction between specialists in narrow and multidisciplinary hospitals as part of the emergency surgery service.Conclusion. When creating specialized medical centers outside of multidisciplinary medical institutions, the possibilities should be provided for the regulated involvement of highly professional consultants with a reasonable algorithm for routing patients in cases of the need for their emergency re-hospitalization to other medical institutions.

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Alexandrescu, Vlad-Adrian, and Didier Van Espen. "Threatening Inferior Limb Ischemia: When to Consider Fasciotomy and What Principles to Apply?" ISRN Vascular Medicine 2014 (March 4, 2014): 1–9. http://dx.doi.org/10.1155/2014/218085.

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Inferior limb compartmental syndrome (CS) gathers a constellation of symptoms that traditionally refers to pathologically increased intramuscular and surrounding tissue pressure generally contained in nonexpansile leg spaces. It associates oftentimes reperfusion or traumatic injury. Intrinsic rigidity of these leg and foot closed compartments may enhance critical pressure risings with deleterious effects on specific vascular and nervous supply, with two main presentations: acute versus chronic display. For these situations, early fasciotomy plays the major role of releasing specific compartment hypertension and prevents deleterious tissue necrosis. Intervention is effective only if required upon precise indications (measured tissue pressure within 20 to 30 mm Hg of systemic diastolic pressure) and performed correctly in a timely fashioned approach. Any failure or delay in recognizing CS inevitably leads to adverse outcomes and jeopardy for secondary limb loss. When judiciously applied during or soon after limb-salvage revascularization technically successful fasciotomy may represent a major contributor in limb preservation. It accounts for a well-defined therapeutic proceeding available for any conscientious and well-briefed interventionist.

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Torbjörnsson, Eva, Ann-Mari Fagerdahl, Lena Blomgren, Lennart Boström, Carin Ottosson, and Jonas Malmstedt. "Risk factors for reamputations in patients amputated after revascularization for critical limb-threatening ischemia." Journal of Vascular Surgery 73, no. 1 (January 2021): 258–66. http://dx.doi.org/10.1016/j.jvs.2020.03.055.

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Pärsson, Håkan N., Niklas Lundin, and Hans Lindgren. "2D perfusion-angiography during endovascular intervention for critical limb threatening ischemia – A feasibility study." JRSM Cardiovascular Disease 9 (January 2020): 204800402091539. http://dx.doi.org/10.1177/2048004020915392.

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Gaylis, H. "Interruption of critical aortoiliac circulation during nonvascularoperations: a cause of acute limb-threatening ischemia." Journal of Vascular Surgery 15, no. 1 (January 1992): 256–57. http://dx.doi.org/10.1016/0741-5214(92)70041-i.

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Sigala, Georgopoulos, Langer, Baunach, Papalambros, Sigalas, Bramis, Bakoyiannis, Bastounis, and Hepp. "Outcome of infrainguinal revascularization for critical limb ischemia in diabetics with end stage renal disease." Vasa 35, no. 1 (February 1, 2006): 15–20. http://dx.doi.org/10.1024/0301-1526.35.1.15.

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Background: End stage renal disease [ESRD] and diabetes have a negative effect on outcome of arterial reconstructions, because they are associated with a vulnerability to infection, an infrageniculate arterial occlusive disease and an increased perioperative risk. The combination of both in critically ischemic patients is traditionally considered a great threat to their limb or life. The risk/benefit ratio of revascularization in this clinical setting is marginal and therefore the decision making is controversial. This study was undertaken to determine the results of arterial reconstruction in patients with end-stage renal disease and diabetes mellitus. Patients and methods: The outcome of 97 patients undergoing 121 arterial reconstructions due to lower limb threatening ischemia were reviewed. Primary and secondary patency rates as well as survival and limb salvage were estimated. Results: Thirty-day operative mortality rate was 10.3%. At one month, one year and 2 year follow-up, the survival rate was 89.7%, 77.6% and 44.2% respectively. Limb salvage at 6 months was 85.6%, at 12 months 75.3% and at 2 years 56.3%. The primary and secondary patency was 92.4% and 93.2% at 6 months and 71.7% and 72.7% at 12 months, respectively. Conclusions: Diabetic patients with ESRD attained an acceptable graft patency and limb salvage but they sustained higher perioperative mortality and morbidity and reduced survival.

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Davies, Mark G., and Tracy J. Cheun. "Influence of a Novel Morphology-Driven Classification on Limb Salvage After Tibial Intervention for Limb-Threatening Critical Ischemia." Journal of Vascular Surgery 68, no. 2 (August 2018): e15. http://dx.doi.org/10.1016/j.jvs.2018.05.057.

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Rudman, V. Ya, K. A. Kalashnikov, and G. A. Burov. "Experience of endovascular treatment of patients with chronic ischemia threatening the loss of a limb." Public health of the Far East Peer-reviewed scientific and practical journal 88, no. 2 (June 1, 2021): 38–43. http://dx.doi.org/10.33454/1728-1261-2021-2-38-43.

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The aim of the study was to assess the technical feasibility of endovascular revascularization of the arteries of the lower extremities in the development of critical ischemia of the lower extremities (chronic ischemia with threatening limb loss), including diabetic foot syndrome. Two clinical cases of endovascular revascularization of lower limb arteries with the development of chronic ischemia with threatening limb loss and diabetic foot syndrome were analyzed. Median age was 61 (60–62) years; there was 1 male (50 %). Upon hospitalization, the risk of limb loss according to the WIfI classification was assessed in one case as high, in the other as medium. The efficiency of revascularization was 100 %. In 1 case (50 %), a second intervention was required. High amputation after surgery during the next year of follow-up was 100 % not necessary. The duration of the operation was 120–150 minutes. The survival rate during the year of follow-up after surgery was 100 %. Clinical observation demonstrates that even with the correct selection of patients, stratification of risk factors for both possible loss of a limb and the risk of surgery, as well as the correctness of the chosen tactics for revascularization of the CPR, only with an increase in the number of procedures performed, routing training and the creation of specialized centers is it possible to achieve satisfactory results in treatment of this problem, which, as the global trend shows, will worsen as the incidence of diabetes increases and the population ages

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Latz, Christopher Alan, Laura Boitano, Linda J. Wang, Anna A. Pendleton, Charles DeCarlo, Brandon Sumpio, Samuel Schwartz, Sunita Srivastava, and Anahita Dua. "Contemporary Endovascular 30-Day Outcomes for Critical Limb Threatening Ischemia Relative to Surgical Bypass Grafting." Vascular and Endovascular Surgery 55, no. 5 (February 19, 2021): 441–47. http://dx.doi.org/10.1177/1538574421989516.

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Objectives: Data from 2011-2014 showed lower extremity bypass(LEB) outperforming infrainguinal endovascular intervention(IEI) regarding major adverse limb events(MALE) but noted no significant difference in major adverse cardiac events(MACE) in propensity matched cohorts. This study aimed to determine if more recent(2015-2018) endovascular outcomes data have improved relative to surgical bypass. Methods: Patients who underwent intervention for chronic limb threatening ischemia (CLTI) from 2015-2018 were identified using the American College of Surgeons National Quality Improvement Program(NSQIP) Vascular Surgery module. The cohort was categorized as undergoing lower extremity bypass(LEB) or infrainguinal endovascular intervention(IEI). Primary 30-day outcomes included major adverse cardiac events(MACE), major adverse limb events(MALE), and major amputation. Inverse probability weighting was used for multivariable analysis. Results: A total of 10,783 patients underwent an infrainguinal intervention for CLTI from 2015-2018. Of these, 6,003(55.7%) underwent LEB and 4,780(44.3%) underwent IEI. Forty percent of the cohort was considered “high anatomic risk” by Objective Performance Goals(OPG) standards, and 13.6% were considered “high clinical risk.” The IEI cohort vs. the LEB cohort experienced a Myocardial infarction(MI)/Stroke rate of 1.8% vs. 3.6%(p < .001), and had a mortality rate of 2.0% vs. 1.7%(p = .22), which yielded a composite MACE of 3.4% vs. 4.8%(p = .001). The rate of reintervention for IEI vs LEB was 4.4% vs. 5.3%(p = .04), the loss of patency (without re-intervention) rate was 1.8% vs. 1.8%(p = 1.0), and the major amputation rate was 4.1% vs. 3.5%(p = .15), which resulted in a MALE rate of 9.1% vs. 8.8%(p = .50). Following inverse probability weighting, comparing the IEI to the referent LEB, MALE AOR = 1.17, 95% CI[1.01 -1.36], p = .036, MACE AOR = 0.61, 95% CI[0.49-0.74], p < .001, and major amputation AOR = 1.31, 95% CI[1.05 -1.62], p = .016. Conclusion: Endovascular outcomes continue to demonstrate inferiority in major amputation and overall MALE. However, endovascular intervention has a significantly reduced incidence of MACE. Overall, these results demonstrate an improvement in endovascular MACE rates in recent years relative to surgical bypass.

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Utsunomiya, Makoto, Mitsuyoshi Takahara, Osamu Iida, Yoshimitsu Soga, Yosuke Hata, Tatsuya Shiraki, Ayumu Nagae, et al. "Limb-Based Patency After Surgical vs Endovascular Revascularization in Patients with Chronic Limb-Threatening Ischemia." Journal of Endovascular Therapy 27, no. 4 (May 20, 2020): 584–94. http://dx.doi.org/10.1177/1526602820923388.

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Purpose: To determine whether limb-based patency (LBP) after infrainguinal revascularization for chronic limb-threatening ischemia (CLTI) is similar between bypass surgery and endovascular therapy (EVT). Materials and Methods: The database for the Surgical Reconstruction vs Peripheral Intervention in Patients With Critical Limb Ischemia (SPINACH) study was interrogated to identify 130 patients (mean age 73±8 years; 94 men) who underwent bypass surgery and 271 patients (mean age 74±10 years; 178 men) who underwent EVT alone. Skin perfusion pressure (SPP) and the ankle-brachial index (ABI) were measured before the procedure and at 0, 1, and 3 months after revascularization. The outcome measure was hemodynamically evaluated LBP (SPP ≥10 mm Hg or ABI ≥0.1) maintained over the first 3 months after treatment. Any reintervention or major amputation was regarded as loss of LBP. The associations between the revascularization strategy (bypass vs EVT) and between the preoperative characteristics and the study outcome (ie, SPP- or ABI-based LBP), were determined using generalized linear mixed models with a logit link function. Patency rates are presented with the 95% confidence interval (CI). Results: The bypass surgery group had a higher stage of limb severity (WIfI) and anatomic complexity (GLASS) than the EVT group, whereas the EVT group had a higher prevalence of heart failure. Both SPP- and ABI-based LBP rates were higher in the bypass group than in the EVT group. SPP-based LBP rates at 3 months were 73.8% (95% CI 63.4% to 84.2%) in the bypass group and 46.2% (95% CI 38.5% to 53.8%) in the EVT group; the corresponding ABI-based LBP rates were 71.5% (95% CI 61.8% to 81.2%) and 44.0% (95% CI 37.3% to 50.7%). Conclusion: LBP is an important concept in the new global vascular guidelines for assessing the anatomic and hemodynamic status of CLTI patients. The present study found that LBP was significantly lower in the EVT group vs the bypass surgery group.

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Porat, Y., S. Baytner-Zamir, M. Niven, L. Shenkman, M. Frogel, and M. Belkin. "A Novel blood-derived treatment for critical limb ischemia (CLI) a life-threatening microvascular disease." Cytotherapy 23, no. 5 (May 2021): S79—S80. http://dx.doi.org/10.1016/s1465324921003893.

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Stella, Jacqueline, Christiane Engelbertz, Katrin Gebauer, Juan Hassu, Matthias Meyborg, Eva Freisinger, and Nasser M. Malyar. "Outcome of patients with chronic limb-threatening ischemia with and without revascularization." Vasa 49, no. 2 (March 1, 2020): 121–27. http://dx.doi.org/10.1024/0301-1526/a000831.

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Summary: Background: Patients with chronic critical limb-threatening ischemia (CLTI) are at high risk of amputation and death. Despite the general recommendation for revascularization in CTLI in the guidelines, the underlying evidence for such a recommendation is limited. The aim of our study was to assess the outcome of patients with CLTI depending on the use of revascularization in a retrospective real-world cohort. Patients and methods: Administrative data of the largest German Health insurance (BARMER GEK) were provided for all patients that were hospitalized for the treatment of CLTI Rutherford category (RF) 5 and 6 between 2009 and 2011. Patients were followed-up until December 31st, 2012 for limb amputation and death in relation to whether patients did (Rx +) or did not have (Rx −) revascularization during index-hospitalization. Results: We identified 15,314 patients with CLTI at RF5 (n = 6,908 (45.1%)) and RF6 (n = 8,406 (54.9%)), thereof 7,651 (50.0%) underwent revascularization (Rx +) and 7,663 (50.0%) were treated conservatively (Rx −). During follow-up (mean 647 days; 95% CI 640–654 days) limb amputation (46.5% Rx− vs. 40.6% Rx+, P < 0.001) and overall mortality (48.2% Rx− vs. 42.6% Rx+, P < 0.001) were significantly lower in the subgroup Rx+. Conclusions: In a real-world setting, only half of CLTI were revascularized during the in-hospital treatment. Though, revascularization was associated with significantly better observed short- and long-term outcome. These data do not allow causal conclusion due to lack of data on the underlying reason for applied or withheld revascularization and therefore may involve a relevant selection bias.

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Tummala, Srini, Ayush Amin, and Ankit Mehta. "Infrapopliteal Artery Occlusive Disease: An Overview of Vessel Preparation and Treatment Options." Journal of Clinical Medicine 9, no. 10 (October 16, 2020): 3321. http://dx.doi.org/10.3390/jcm9103321.

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Critical limb ischemia (CLI) is defined as chronic rest pain and/or the presence of tissue loss (ulcers or gangrene) in the lower extremities secondary to ischemia. CLI is a limb and potentially life-threatening disease associated with a poor prognosis with only 50% of patients being able to preserve both limbs within 12 months of diagnosis. CLI related to diabetes is often more extensive with multi-level long segmental arterial disease resulting in a 5–30-fold increased rate of amputation. As the incidence and prevalence of diabetes mellitus increases within our aging society, the rate of infrapopliteal artery occlusive disease (IPOD) and the need for intervention rises with it. The aim of this manuscript is to provide the reader with an overview of the various devices available for vessel preparation (VP) and treatment of IPOD in order to optimize patency rates, symptom resolution, healing of wounds, and minimize complications.

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Mustapha, Jihad A., Bynthia M. Anose, Brad J. Martinsen, George Pliagas, Joseph Ricotta, Christopher W. Boyes, Michael S. Lee, Fadi Saab, and George Adams. "Lower extremity revascularization via endovascular and surgical approaches: A systematic review with emphasis on combined inflow and outflow revascularization." SAGE Open Medicine 8 (January 2020): 205031212092923. http://dx.doi.org/10.1177/2050312120929239.

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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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Chigidinova, D. S., B. A. Rudenko, A. S. Shanoyan, V. P. Mazaev, and F. B. Shukurov. "Endovascular Treatment of Acute Tibioperoneal Trunk Thrombosis. A Clinical Case Report." Creative surgery and oncology 9, no. 2 (July 29, 2019): 113–17. http://dx.doi.org/10.24060/2076-3093-2019-9-2-113-117.

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Introduction. Acute limb ischemia is a severe disorder caused by a sharp drop in the arterial perfusion of the limb. It carries a threat to the limb’s function and viability. The issue of early recognition of acute limb ischemia in surgery is both important and difficult. The current guidelines recommend that patients with acute limb ischemia when the limb is viable should be urgently examined and treated. Restoring the blood flow in patients with acute limb ischemia is a priority, since a significant reduction in arterial perfusion can lead to limb amputation and life-threatening complications. In acute limb ischemia different treatment methods can be used, both open surgery and endovascular procedures. The treatment strategy depends on the localisation, duration of ischemia, neurological deficit, concomitant diseases and risks associated with treatment and its results. Endovascular procedures on the arteries of the lower leg are most often indicated to save a limb. Endovascular procedures on the arteries of the lower leg are indicated more often in patients with critical limb ischemia. Endovascular procedures when the condition is primary demonstrate good outcomes and high efficiency on the arteries of the lower extremities at all levels of the lesion.Materials and methods. This paper presents a clinical case of a successful endovascular procedure performed for the treatment of acute thrombosis of the arteries of the lower leg. Three stents were implanted, with a good angiographically confirmed outcome.Conclusion. Endovascular balloon angioplasty with stenting of the tibioperoneal trunk can result in good outcomes in patients with acute thrombosis of the arteries of the lower leg.

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Papaconstantinou, Harry T., Dennis M. Fry, Joseph Giglia, James Hurst, and John D. Edwards. "Endovascular Repair of a Blunt Traumatic Axillary Artery Injury Presenting with Limb-Threatening Ischemia." Journal of Trauma: Injury, Infection, and Critical Care 57, no. 1 (July 2004): 180–83. http://dx.doi.org/10.1097/01.ta.0000058310.03167.a5.

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Essa, Rawand Abdulrahman, and Sirwan Khalid Ahmed. "Case Report: Acute lower limb ischemia in a recovered COVID-19 patient." F1000Research 9 (October 19, 2020): 1253. http://dx.doi.org/10.12688/f1000research.26603.1.

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Arterial thrombosis is rarely reported in relation to COVID-19 patients. It occurs mostly in critical patients especially those with acute respiratory distress syndrome and patients in intensive care units. The cause of arterial thrombosis is mostly related to a cytokine storm. However, limited studies are available regarding arterial thrombosis in COVID-19 disease. Here, we present a case of lower limb ischemia in a moderately symptomatic COVID-19 patient in Iraq within three days after recovery from COVID-19. The patient presented with severe right lower limb pain, forefoot, cyanosed toes, and lower limb ischemia was diagnosed by physical examination and ultrasound. The patient was successfully treated by anticoagulant drugs. Our case alerts healthcare workers that they need to be more cautious of life threatening COVID-19 complications in order to begin early and effective preventive measures.

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Barat, Sorin, and Dumitru Casian. "Off-Label Use of a Double-Layer Micromesh Carotid Stent for Hybrid Treatment of Popliteal Artery Aneurism Complicated by Chronic Distal Embolization." Case Reports in Vascular Medicine 2021 (June 21, 2021): 1–6. http://dx.doi.org/10.1155/2021/5546194.

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We report our initial experience in off-label use of the double-layer micromesh (DLM) Roadsaver® stent for the hybrid treatment of a fusiform popliteal artery aneurism complicated by distal embolization and chronic limb threatening ischemia in a COVID-19-positive young male. A 36-year-old male patient was admitted with chronic limb threatening ischemia of the left lower limb. The duplex ultrasound and computer tomography angiography (CTA) demonstrated a fusiform popliteal artery aneurism with a maximal diameter of 14 mm and distal occlusion of peroneal and both tibial arteries. Urgent hybrid intervention was performed, starting with an open thrombectomy from the distal posterior tibial artery via a retromalleolar access followed by percutaneous deployment of the DLM Roadsaver® stent (Terumo, Tokyo, Japan) for the exclusion of the popliteal artery aneurism. The flow diverting effect was observed immediately with contrast stagnation in the asymmetrical part of the aneurism sac (grade C2 of the O’Kelly-Marotta flow diversion scale). The procedure was uneventful, with the regaining of an adequate foot perfusion and palpable pulse at the posterior tibial artery. On the 2nd postoperative day, the patient was diagnosed with a symptomatic form of COVID-19 infection and transferred to a dedicated facility. At a one-month follow-up, the patient had no symptoms of limb ischemia and CTA showed complete thrombosis of the aneurism sac, absence of endoleaks, and patency of the treated arterial segment. This case demonstrates the possibility of off-label use of the DLM Roadsaver® stent for hybrid treatment of popliteal artery aneurism complicated by distal embolization and critical limb ischemia.

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Dietzek, Alan M., Jamie Goldsmith, Frank J. Veith, Luis A. Sanchez, Sushil K. Gupta, and Kurt R. Wengerter. "Interruption of critical aortoiliac collateral circulation during nonvascular operations: A cause of acute limb-threatening ischemia." Journal of Vascular Surgery 12, no. 6 (December 1990): 645–53. http://dx.doi.org/10.1067/mva.1990.25254.

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Sigala, Menenakos, Sigalas, Baunach, Langer, Papalambros, and Hepp. "Transluminal angioplasty of isolated crural arterial lesions in diabetics with critical limb ischemia." Vasa 34, no. 3 (August 1, 2005): 186–91. http://dx.doi.org/10.1024/0301-1526.34.3.186.

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Background: We investigated the long-term clinical results of transluminal angioplasty of isolated infrapopliteal arteries in diabetic patients with severe ischaemic foot lesions and the influence of different parameters on primary success, the long-term outcome and the survival rate. Patients and methods: Between January 2001 and May 2004 we performed 50 transluminal angioplasties in 52 (10 female, 42 male, mean age 69.3 years) diabetics with isolated lesions of crural arteries (tibio-peroneal trunk 41, anterior tibial 13, posterior tibial 5, peroneal artery 14) and limb threatening ischaemia (rest pain 12, tissue loss 40). In two patients the dilatation could not be performed due to vessel perforation and impossibility to catheter localization. The morphological classification of infrapopliteal lesions was determined according to guidelines provided by TransAtlantic Inter-Society Consensus (TASC) (17 type A, 16 type B, 13 type C, 4 type D). Results: Initial technical success after angioplasty of crural arteries could be obtained in 96%.Kaplan-Meier analysis showed a cumulative limb salvage of 92%,85% and 68, 9% after 6 months,one and two years, respectively. Patients falling in TASC group C had significantly higher risk of amputation. Overall survival at 1 year was calculated at 85% and at 2 years at 65%. Conclusion: Our results suggest that depending on the extent of lesions transluminal angioplasty of infrapopliteal artery stenoses and occlusions is considered as an effective and save therapy modality to avoid limb loss in diabetics with critical ischemia.

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Alcocer, Francisco, William D. Jordan, Douglas J. Wirthlin, and David Whitley. "Early Results of Lower Extremity Infrageniculate Revascularization with a New Polytetrafluoroethylene Graft." Vascular 12, no. 5 (September 2004): 318–24. http://dx.doi.org/10.1258/rsmvasc.12.5.318.

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When an autologous vein is not available for lower extremity revascularization, prosthetic grafts are often required. However, prosthetic bypass grafts have limited patency for infrageniculate reconstruction. To potentially improve patency, a new geometric modification of the polytetrafluoroethylene (PTFE) graft, Distaflo (Impra, Tempe, AZ), has been developed for lower extremity bypass. We reviewed our early experience with the Distaflo graft in patients who required infrageniculate bypass for lower extremity ischemia when no suitable autologous saphenous vein was available. All patients were maintained on warfarin anticoagulation postoperatively. All grafts were followed at 6- to 12-week intervals with duplex ultrasound evaluation. Patient characteristics, operative procedures, and graft surveillance information were maintained on a computerized registry. Thirty-two patients with limb-threatening ischemia underwent 35 infrageniculate reconstructions with a Distaflo graft between February 26, 1999, and August 24, 2000. Thirty-two of 35 bypasses were performed on extremities that had previously undergone a surgical procedure. Forty-eight previous revascularization procedures were done on these 25 extremities. Thirty grafts were constructed to the tibial outflow sites, whereas the remaining five grafts were placed to the below-knee popliteal artery. One patient died on the second postoperative day secondary to unrelated causes, and only one graft (3%) failed during the same hospitalization. Fifteen of 35 grafts (43%) remained patent 1 to 30 months later. Four patent grafts (6%) were ligated between 2 and 14 months for infectious indications. When considering the 20 failed grafts, 9 patients underwent major amputation, 5 patients remain with chronically ischemic limbs, and 6 patients underwent additional bypass grafts. Twenty-three patients (72%) maintained limb salvage. The Distaflo PTFE graft achieves promising early patency for complex infrageniculate revascularization and may be used as an alternative conduit in patients with critical limb ischemia who do not have an adequate vein for lower extremity revascularization.

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Argyriou, Christos, Nikolaos Schoretsanitis, Konstantia Kantartzi, Stylianos Panagoutsos, Vasileios D. Souftas, Miltos K. Lazarides, and George S. Georgiadis. "Use of a temporary shunt to preserve the patency of a hemodialysis graft while performing ipsilateral axillo-femoral bypass." Journal of Vascular Access 20, no. 5 (January 8, 2019): 553–56. http://dx.doi.org/10.1177/1129729818820205.

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Increased blood flow in the subclavian artery feeding a vascular access for hemodialysis can rarely induce steal phenomena in the vertebral and internal mammary artery leading to potentially life-threatening conditions. On the contrary, transient interruption of blood flow in the subclavian artery feeding a dialysis arteriovenous fistula can theoretically induce access thrombosis. Here, we describe a technical maneuver preserving continuous ipsilateral upper arm access flow when constructing a unilateral axillo-femoral polytetrafluoroethylene bypass operation for critical limb ischemia in a hemodialysis patient.

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Shiraki, Tatsuya, Osamu Iida, Shin Okamoto, Takuya Tsujimura, Yosuke Hata, Mitsuyoshi Takahara, Toshiaki Mano, and Yasushi Sakata. "Long-Term Clinical Outcomes after Endovascular Therapy for Anti-Centromere Antibody-Positive Patients with Critical Limb-Threatening Ischemia." Journal of Vascular and Interventional Radiology 31, no. 12 (December 2020): 1993–97. http://dx.doi.org/10.1016/j.jvir.2020.07.013.

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Fisker, Lasse, Jonas Eiberg, Henrik Sillesen, and Martin Lawaetz. "The Role of Routine Ultrasound Surveillance after In Situ Infrainguinal Peripheral Vein Bypass for Critical Limb-Threatening Ischemia." Annals of Vascular Surgery 66 (July 2020): 529–36. http://dx.doi.org/10.1016/j.avsg.2020.01.092.

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Binay Safer, Vildan, Ilker Tasci, and Umut Safer. "Comment on “Usefulness of Platelet-To-Lymphocyte Ratio as a Marker of Sarcopenia for Critical Limb Threatening Ischemia”." Annals of Vascular Surgery 68 (October 2020): e583-e584. http://dx.doi.org/10.1016/j.avsg.2020.06.045.

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Mosalli, Rafat, Mohamed Elbaz, and Bosco Paes. "Topical Nitroglycerine for Neonatal Arterial Associated Peripheral Ischemia following Cannulation: A Case Report and Comprehensive Literature Review." Case Reports in Pediatrics 2013 (2013): 1–7. http://dx.doi.org/10.1155/2013/608516.

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Arterial cannulation in neonates is usually performed for frequent blood pressure monitoring and blood sampling. The procedure, while easily executed by skilled neonatal staff, can be associated with serious complications such as vasospasm, thrombosis, embolism, hematoma, infection, peripheral nerve damage, ischemia, and tissue necrosis. Several treatment options are available to reverse vascular induced ischemia and tissue damage. Applied interventions depend on the extent of tissue involvement and whether the condition is progressive and deemed life threatening. Standard, noninvasive measures include immediate catheter removal, limb elevation, and warming the contralateral extremity. Topical vasodilators, anticoagulation, thrombolysis, and surgery are considered secondary therapeutic strategies. A comprehensive literature search indicates that topical nitroglycerin has been utilized for the treatment of tissue ischemia in three preterms with umbilical arterial catheters and four with peripheral arterial lines. We report the first successful use of nitroglycerine ointment in a critically ill preterm infant with ischemic hand changes after brachial artery cannulation.

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Miyata, T., S. Mii, H. Kumamaru, A. Takahashi, H. Miyata, K. Shigematsu, N. Azuma, et al. "Risk prediction model for early outcomes of revascularization for chronic limb-threatening ischaemia." British Journal of Surgery 108, no. 8 (March 6, 2021): 941–50. http://dx.doi.org/10.1093/bjs/znab036.

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Abstract Background Quantifying the risks and benefits of revascularization for chronic limb-threatening ischaemia (CLTI) is important. The aim of this study was to create a risk prediction model for treatment outcomes 30 days after revascularization in patients with CLTI. Methods Consecutive patients with CLTI who had undergone revascularization between 2013 and 2016 were collected from the JAPAN Critical Limb Ischemia Database (JCLIMB). The cohort was divided into a development and a validation cohort. In the development cohort, multivariable risk models were constructed to predict major amputation and/or death and major adverse limb events using least absolute shrinkage and selection operator logistic regression. This developed model was applied to the validation cohort and its performance was evaluated using c-statistic and calibration plots. Results Some 2906 patients were included in the analysis. The major amputation and/or mortality rate within 30 days of arterial reconstruction was 5.0 per cent (144 of 2906), and strong predictors were abnormal white blood cell count, emergency procedure, congestive heart failure, body temperature of 38°C or above, and hemodialysis. Conversely, moderate, low or no risk in the Geriatric Nutritional Risk Index (GNRI) and ambulatory status were associated with improved results. The c-statistic value was 0.82 with high prediction accuracy. The rate of major adverse limb events was 6.4 per cent (185 of 2906), and strong predictors were abnormal white blood cell count and body temperature of 38°C or above. Moderate, low or no risk in the GNRI, and age greater than 84 years were associated with improved results. The c-statistic value was 0.79, with high prediction accuracy. Conclusion This risk prediction model can help in deciding on the treatment strategy in patients with CLTI and serve as an index for evaluating the quality of each medical facility.

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Orrapin, Saritphat, and Kittipan Rekasem. "Role of Topical Biological Therapies and Dressings in Healing Ischemic Wounds." International Journal of Lower Extremity Wounds 17, no. 4 (December 2018): 236–46. http://dx.doi.org/10.1177/1534734618815360.

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Ischemic wounds are the most severe expression of critical limb ischemia (CLI), and they have been defined clinically as an end stage of peripheral arterial disease. Urgent revascularization is a fundamental part for limb salvage in patients with CLI. However, the risk of revascularization should be weighed against the likelihood of success given a patient’s life-threatening comorbidities. Once the condition of arterial insufficiency is revascularized, wound care is an important aspect to promote the wound healing process and infection control. MOIST concept for wound care is a modern systematic treatment for enhanced wound healing process. Currently, advanced biological therapies are emerging in ischemic wound therapies to restore the wound healing process and involve active biological agents to support the wound healing process. We studied and summarized the different types of available topical biological therapies and their mechanisms on the healing process including platelet-derived growth factor, epidermal growth factor, fibroblast growth factor, and vascular endothelial growth factor, platelet-rich plasma, and honey for local wound care of patient with CLI. Our review suggests that topical platelet-derived growth factor, epidermal growth factor, platelet-rich plasma, and honey are available as well as considered in the ischemic wound healing process enhancement through the MOIST concept. In conclusion, biologic wound dressing or topical agent therapy may improve the wound healing process, increase limb salvage, is inexpensive, and provides potential safety with nontoxic low-risk therapy in patients with an ischemic wound. Thus, local wound care by biological dressing should be added in adjuvant treatment for ischemic wound patients. However, further randomized studies are needed to support efficacy and long-term outcomes of these biological dressing in patients with ischemic wound.

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Said, Ahmad, Phillip Kraft, and Luay Sayed. "Delayed Yet Successful Mechanical Thrombectomy for Phlegmasia Cerulea Dolens in a Limb with Severe Arterial Disease and May-Thurner Syndrome." Case Reports in Vascular Medicine 2020 (November 1, 2020): 1–5. http://dx.doi.org/10.1155/2020/8866030.

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Phlegmasia cerulea dolens (PCD) is a rare but life-threatening complication of acute deep venous thrombosis that lacks consensus regarding the approach to management. We present a case of PCD developing shortly after a spinal surgery and manifesting as acute swelling and discoloration in a leg with existing severe atherosclerotic arterial disease. The patient’s critical limb ischemia was completely and rapidly reversed by percutaneous mechanical thrombectomy using the ClotTriever device despite a delay in treatment. An underlying iliac vein compression “May-Thurner” syndrome was discovered using intravascular ultrasound and treated with angioplasty. This case identifies mechanical thrombectomy using the ClotTriever system as a possible effective and safe treatment for PCD.

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Katelnitsky, I. I., V. V. Darvin, and A. A. Zorkin. "Comprehensive treatment of patients with chronic limb-threatening ischaemia: are we using all the possibilities of anticoagulant therapy?" Russian Medical Inquiry 4, no. 7 (2020): 445–51. http://dx.doi.org/10.32364/2587-6821-2020-4-7-445-451.

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Background: medical correction of the hemostatic system is one of the most important directions for complex treatment of obliterating diseases of lower limbs arteries (ODLLA), including cases of chronic limb-threatening ischaemia (CLTI).Aim: to evaluate the efficacy and safety of the sulodexide use in patients with ODLLA when conducting a comprehensive treatment of CLTI.Patients and Methods: 520 patients underwent two-center prospective study, 318 of whom (211 — with signs of ODLLA, 107 — without signs of CLTI) underwent revascularization interventions, whereas, 202 patients with CLTI received multicomponent complex conservative treatment. In addition to standard treatment, 30 patients who underwent surgery interventions and the group of 50 patients receiving conservative treatment received sulodexide orally in 2 capsules bis in day (1000 LE/day). The severity of the pain syndrome, the distance of pain-free walking, some laboratory indicators of hemostatic system, as well as the presence of adverse events and complications were evaluated before and after treatment. Results: in operated patients with both CLTI and without it, regardless of the sulodexide use, there was a significant decrease in the severity of pain syndrome and an increase in the distance of pain-free walking. Sulodexide use was accompanied by reduced fibrinogen, D-dimer, soluble fibrin monomer complexes (SFMC) and plasminogen activator inhibitor (PAI-1) in the subgroup of patients with CLTI, and indicators of fibrinogen and PAI-1 in the subgroup of patients without CLTI (p<0.05). In non-operated patients with CLTI, sulodexide use was accompanied by a decrease in pain syndrome and indicators of fibrinogen, D-dimer, SFMC, and PAI-1 (p<0.05). However, it was less significant after performed revascularization. There were no adverse events or complications associated with the sulodexide use.Conclusions: improvement of clinical and laboratory parameters was mainly determined by the efficacy of performed limb revascularization. In the complex treatment of patients with ODLLA, the sulodexide use was safe and effective, which was manifested by a decrease in the pain severity, an increase in the distance of pain-free walking and normalization of some coagulogram indicators.KEYWORDS: chronic limb-threatening ischaemia, critical limb ischemia, obliterating diseases of lower limb arteries, complex treatment, sulodexide.FOR CITATION: Katelnitsky I.I., Darvin V.V., Zorkin A.A. Comprehensive treatment of patients with chronic limb-threatening ischaemia: are we using all the possibilities of anticoagulant therapy? Russian Medical Inquiry. 2020;4(7):445–451. DOI: 10.32364/2587-6821-2020-4-7-445-451.

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Konijn, Louise C. D., Richard A. P. Takx, Willem P. Th M. Mali, Hugo T. C. Veger, and Hendrik van Overhagen. "Different Lower Extremity Arterial Calcification Patterns in Patients with Chronic Limb-Threatening Ischemia Compared with Asymptomatic Controls." Journal of Personalized Medicine 11, no. 6 (May 31, 2021): 493. http://dx.doi.org/10.3390/jpm11060493.

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Objectives: The most severe type of peripheral arterial disease (PAD) is critical limb-threatening ischemia (CLI). In CLI, calcification of the vessel wall plays an important role in symptoms, amputation rate, and mortality. However, calcified arteries are also found in asymptomatic persons (non-PAD patients). We investigated whether the calcification pattern in CLI patients and non- PAD patients are different and could possibly explain the symptoms in CLI patients. Materials and Methods: 130 CLI and 204 non-PAD patients underwent a CT of the lower extremities. This resulted in 118 CLI patients (mean age 72 ± 12, 70.3% male) that were age-matched with 118 non-PAD patients (mean age 71 ± 11, 51.7% male). The characteristics severity, annularity, thickness, and continuity were assessed in the femoral and crural arteries and analyzed by binary multiple logistic regression. Results: Nearly all CLI patients have calcifications and these are equally frequent in the femoropopliteal (98.3%) and crural arteries (97.5%), while the non-PAD patients had in just 67% any calcifications with more calcifications in the femoropopliteal (70.3%) than in the crural arteries (55.9%, p < 0.005). The crural arteries of CLI patients had significantly more complete annular calcifications (OR 2.92, p = 0.001), while in non-PAD patients dot-like calcifications dominated. In CLI patients, the femoropopliteal arteries had more severe, irregular/patchy, and thick calcifications (OR 2.40, 3.27, 1.81, p ≤ 0.05, respectively) while in non-PAD patients, thin continuous calcifications prevailed. Conclusions: Compared with non-PAD patients, arteries of the lower extremities of CLI patients are more frequently and extensively calcified. Annular calcifications were found in the crural arteries of CLI patients while dot-like calcifications were mostly present in non-PAD patients. These different patterns of calcifications in CLI point at different etiology and can have prognostic and eventually therapeutic consequences.

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Katsaros, Ioannis, Efstratios Georgakarakos, Konstantinos Frigkas, Kalliopi-Maria Tasopoulou, Vasileios Souftas, and Aliki Fiska. "Arterial collateral circulation pathways in patients with aortoiliac occlusive disease." Vascular 27, no. 6 (June 27, 2019): 677–83. http://dx.doi.org/10.1177/1708538119859795.

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Objectives Aortoiliac occlusive disease is a leading cause of morbidity and mortality worldwide. Patients typically present with intermittent claudication or critical limb ischemia but the majority of them remain asymptomatic. Collateral arterial pathways restore the arterial blood supply distal to the lesions. The objective of this study is the description of collateral pathways’ patterns of aortoiliac occlusive disease. Methods Records from the Department of Vascular Surgery of University General Hospital of Alexandroupolis were retrospectively searched from March 2016 to August 2018 for patients suffering from aortoiliac occlusive disease. Results Thirty-three patients (24 males, 9 females) with a mean age of 64.2 ± 11.8 years were included in this study. Twenty-two patients had diabetes mellitus, 25 hypertension, and 16 dyslipidemia. Twenty-two were active smokers. Seventeen patients suffered from intermittent claudication and 16 patients presented with critical limb ischemia. Seven patients had TASC-II B lesions, 10 TASC-II C lesions, and 16 patients had TASC-II D lesions. Systemic collateral pathways were dominant in 17 patients, whereas visceral pathways were prominent in 16 patients. While 62.5% of patients having lesions in the abdominal aorta presented systemic pathways, the lesions located only in the iliac arteries followed visceral patterns or systematic patterns equally. Conclusions Collateral anastomotic networks provide blood supply to regions distal to aortoiliac occlusive lesions. Their pattern is defined mainly by the location of the lesion and does not seem to associate with comorbid factors or the extent of the lesion. Failure to recognize these networks during surgery could lead to limb threatening situations.

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Wijnand, Joep, Warren J. Gasper, M. C. Verhaar, G. J. de Borst, and Michael S. Conte. "IF02. Angiographic Patterns at the Ankle and Foot Level in Patients With Critical Limb-Threatening Ischemia Correlate With Healing of Transmetatarsal Amputation." Journal of Vascular Surgery 69, no. 6 (June 2019): e45-e46. http://dx.doi.org/10.1016/j.jvs.2019.04.003.

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P. Wu, Lily, Nadraj G. Naidoo, and Olatunji O. Adetokunboh. "Predictors of post-operative outcomes in patients with peripheral arterial disease and critical limb ischaemia: a systematic review and meta-analysis." Ghana Medical Journal 55, no. 1 (March 31, 2021): 69–76. http://dx.doi.org/10.4314/gmj.v55i1.10.

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Background: A very small proportion (1%) of patients with peripheral artery disease (PAD) present with critical limb threatening ischaemia (CLTI) with poor prognosis. The present review showcased several pre-operative predictors and key post-operative outcomes. Identification of any modifiable predictors may impact positively on surgical outcomes.Design: PubMed/Medline, Google scholar and Cochrane databases were searched using terms such as “peripheral arterial disease” AND “critical limb ischemia,” “post-operative outcome,” AND “predictors of post-operative outcomes”. Search was for relevant English-language articles published between January 1997 and December 2007 Selected articles were screened first by title and abstract, and selection of full articles was based on relevance using our inclusion and exclusion criteria and quality ratings performed with the MINORS score.Results: The included studies were published between 1997 and 2007. Only six (6) articles out of a total of 2,114 were deemed suitable for analysis. Ambulatory recovery was >70% at six months, 86.7% and 70.0% at one year and five years respectively. Rate of local wound complications was between 12% and 24%. Reported limb salvage rates were >90% at six months, >70% at one year and 70.0-90.0% at five years. Primary graft patency rate at one year ranged from 63% and 76.6%. Gangrene, diabetes and impaired pre-operative ambulatory function are associated with more wound complications, low limb salvage, reduced graft patency and poor functional outcome.Conclusion: Pre-operative ambulatory status was the most important predictor of post-operative ambulatory recovery. Diabetes mellitus was an important risk factor for prolonged wound healing, local wound complications and major amputation.

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Journal articles on the topic 'Critical limb threatening ischemia'

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