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Trihan JE, Croquette M, Hersant J, Prigent R, Fontaine C, Henni S, Lanéelle D. Accuracy of maximal acceleration time of pedal arteries to diagnose critical limb-threatening ischemia. Vasc Med 2024; 29:153-162. [PMID: 38469710 DOI: 10.1177/1358863x231226216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
INTRODUCTION Maximal acceleration time of distal arteries of the foot (ATmax) is correlated to ankle-brachial index (ABI) and toe-brachial index (TBI), and seems very promising in diagnosing severe peripheral artery disease (PAD) and especially critical limb-threatening ischemia (CLTI). Our goal was to confirm the cut-off value of 215 ms to predict a toe pressure (TP) ⩽ 30 mmHg. METHODS A 4-month retrospective study was conducted on patients addressed for suspicion of PAD. Demographic data, ABI, TBI, and Doppler ultrasound scanning parameters of the dorsal pedis and lateral plantar arteries (DPA and LPA) were recorded. RESULTS A total of 137 patients with 258 lower limbs were included. ATmax was highly correlated to TBI (r = -0.89, p < 0.001). With the cut-off value of 215 ms, ATmax was effective to diagnose TP ⩽ 30 mmHg with a sensitivity of 93% [95% CI 77-99], a specificity of 96% [95% CI 92-98], a positive predictive value of 73% [95% CI 56-86], a negative predictive value of 99% [95% CI 97-100], and an area under the receiver operating characteristics curve of 0.99 [95% CI 0.98-1.00]. ATmax also showed promising results to rule out PAD in healthy patients. CONCLUSION ATmax is a reliable diagnostic tool to diagnose low TP and could be a new easily performed hemodynamic criterion for diagnosis of CLTI.
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Affiliation(s)
- Jean-Eudes Trihan
- Vascular Medicine Unit, Hospital of Cholet, Cholet, Pays de la Loire, France
- Vascular Medicine Department, University Hospital Angers, Angers, Pays de la Loire, France
| | - Magali Croquette
- Vascular Medicine Unit, University Hospital Centre Poitiers, Poitiers, Nouvelle-Aquitaine, France
| | - Jeanne Hersant
- Vascular Medicine Department, University Hospital Angers, Angers, Pays de la Loire, France
- UMR CNRS 1083, INSERM 6015, LUNAM University, Angers, France
| | - Romain Prigent
- Vascular Medicine Unit, Hospital of Cholet, Cholet, Pays de la Loire, France
| | - Cedric Fontaine
- Vascular Medicine Unit, Hospital of Cholet, Cholet, Pays de la Loire, France
| | - Samir Henni
- Vascular Medicine Department, University Hospital Angers, Angers, Pays de la Loire, France
- UMR CNRS 1083, INSERM 6015, LUNAM University, Angers, France
| | - Damien Lanéelle
- Vascular Medicine Unit, University Hospital Côte de Nacre, Caen, Normandie, France
- UNICAEN, INSERM 1075, COMETE, Caen, Normandie, France
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Argyriou C, Lazarides MK, Georgakarakos E, Georgiadis GS. Role of Hemodynamic Assessment and Limitations in Ankle-Brachial Pressure Index, Toe- Brachial Pressure Index to Predict Wound Healing After Revascularization. INT J LOW EXTR WOUND 2024; 23:7-11. [PMID: 37933181 DOI: 10.1177/15347346231212782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Chronic limb-threatening ischemia (CLTI) represents one of the most severe forms of peripheral arterial disease implying impaired wound healing and tissue loss at the same time posing a significant impact on the quality of life of patients and a serious economic burden on healthcare systems around the world. A major challenge in the management of patients with CLTI is the validity and role of non-invasive hemodynamic parameters in assessing their clinical status before and after revascularization. Traditionally, the diagnosis of CLTI is routinely based on clinical symptoms and confirmed by measurements of non-invasive limb hemodynamics including ankle-brachial pressure index (ABPI) and toe-brachial pressure index (TBPI). However, whether these indices alone can provide definitive treatment or be used as adjunctive tool along with the implementation of novel techniques to help guide revascularization for CLI patients still remains unclear.
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Affiliation(s)
- Christos Argyriou
- Department of Vascular Surgery, "Democritus" University of Thrace, University Hospital of Alexandroupolis, Alexandroupoli, Greece
| | - Miltos K Lazarides
- School of Medicine, "Democritus" University of Thrace, Alexandroupolis, Greece
| | - Efstratios Georgakarakos
- Department of Vascular Surgery, "Democritus" University of Thrace, University Hospital of Alexandroupolis, Alexandroupoli, Greece
| | - George S Georgiadis
- Department of Vascular Surgery, "Democritus" University of Thrace, University Hospital of Alexandroupolis, Alexandroupoli, Greece
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Popitiu MI, Alexandrescu VA, Clerici G, Ionac S, Gavrila-Ardelean G, Ion MG, Ionac ME. Angiosome-Targeted Infrapopliteal Angioplasty: Impact on Clinical Outcomes-An Observational Study. J Clin Med 2024; 13:883. [PMID: 38337576 PMCID: PMC10856460 DOI: 10.3390/jcm13030883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/22/2024] [Accepted: 01/26/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Revascularization based on the angiosome concept (AC) is a controversial subject because there is currently no clear evidence of its efficacy, due to the heterogeneity of patients (multiple and diverse risk factors and comorbidities, multiple variations in the affected angiosomes). Choke vessels change the paradigm of the AC, and the presence or absence of the plantar arch directly affects the course of targeted revascularization. The aim of this study was to evaluate the effect of revascularization based on the AC in diabetic patients with chronic limb-threatening ischemia (CLTI). Methods: This retrospective analysis included 51 patients (40 men, 11 women), with a mean age of 69 years (66-72) and a total of 51 limbs, who presented with Rutherford 5-6 CLTI, before and after having undergone a drug-coated balloon angioplasty (8 patients) or plain balloon angioplasty (43). Between November 2018 and November 2019, all patients underwent below-the-knee balloon angioplasties and were followed up for an average of 12 months. The alteration of microcirculation was compared between directly and indirectly revascularized angiosomes. The study assessed clinical findings and patient outcomes, with follow-up investigations, comparing wound healing rates between the different revascularization methods. Patient records and periprocedural leg digital subtraction angiographies (DSA) were analyzed. Differences in outcomes after direct revascularization and indirect percutaneous transluminal angioplasty (PTa) were examined using Cox proportional hazards analysis, with the following endpoints: ulcer healing, limb salvage, and also amputation-free survival. Results: Direct blood flow to the angiosome supplying the ulcer area was achieved in 38 legs, in contrast to 13 legs with indirect revascularization. Among the cases, there were 39 lesions in the anterior tibial artery (ATA), 42 lesions in the posterior tibial artery (PTA), and 8 lesions in the peroneal artery (PA). According to a Cox proportional hazards analysis, having fewer than three (<3) affected angiosomes (HR 0.49, 95% CI 0.19-1.25, p = 0.136) was associated with improved wound healing. Conversely, wound healing outcomes were least favorable after indirect angioplasty (p = 0.206). When adjusting the Cox proportional hazard analysis for the number of affected angiosomes, it was found that direct drug-coated angioplasty resulted in the most favorable wound healing (p = 0.091). At the 1-year follow-up, the major amputation rate was 17.7%, and, according to a Cox proportional hazards analysis, atrial fibrillation (HR 0.85, 95% CI 0.42-1.69, p = 0.637), hemodialysis (HR 1.26, 95% CI 0.39-4.04, p = 0.699), and number of affected angiosomes > 3 (HR 0.94, 95% CI 0.63-1.39, p = 0.748) were significantly associated with poor leg salvage. Additionally, direct endovascular revascularization was associated with a lower rate of major amputation compared to indirect angioplasty (HR 1.09, 95% CI 0.34-3.50, p = 0.884). Conclusions: Observing the angiosomes concept in decision-making appears to result in improved rates of arterial ulcer healing and leg salvage, particularly in targeted drug-coated balloon angioplasty for diabetic critical limb ischemia, where multiple angiosomes are typically affected.
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Affiliation(s)
- Mircea Ionut Popitiu
- Research Center in Vascular and Endovascular Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.); (G.G.-A.); (M.G.I.); (M.E.I.)
| | - Vlad Adrian Alexandrescu
- Cardio-Vascular and Thoracic Surgery Department, CHUp Sart-Tilman Hospital, University of Liège, 4000 Liège, Belgium;
| | | | - Stefan Ionac
- Research Center in Vascular and Endovascular Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.); (G.G.-A.); (M.G.I.); (M.E.I.)
| | - Gloria Gavrila-Ardelean
- Research Center in Vascular and Endovascular Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.); (G.G.-A.); (M.G.I.); (M.E.I.)
| | - Miruna Georgiana Ion
- Research Center in Vascular and Endovascular Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.); (G.G.-A.); (M.G.I.); (M.E.I.)
| | - Mihai Edmond Ionac
- Research Center in Vascular and Endovascular Surgery, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania; (S.I.); (G.G.-A.); (M.G.I.); (M.E.I.)
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Laivuori M, Peltonen E, Venermo M, Hakovirta H. Incompressible ankle arteries predict increased morbidity and mortality in patients with an elevated ankle brachial index. Vascular 2024; 32:110-117. [PMID: 36113169 DOI: 10.1177/17085381221127051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2024]
Abstract
OBJECTIVES Patients with an elevated ankle brachial index (ABI) > 1.3 have a high burden of disease and poorer outcome compared to patients with a lower ABI. Previously differences between patients with ABI > 1.3 have not been studied in detail. The aim of this study was to analyze the morbidity and mortality of patients with ABI > 1.3. METHODS ABI measurements were performed in the vascular laboratory of Turku university hospital 2011-2013. Patients with ABI>1.3 in at least one lower limb were included in the study and divided into 3 groups: At least one lower limb ABI 1.3-2.5 but both limbs <2.5 (group 1), one limb ABI ≥2.5 (group 2), both limbs ABI ≥ 2.5 (group 3). RESULTS 534 patients were included in the study. The patients in groups 2 and 3 were more often female (p < .001), older (p < .001), had more diabetes (p = .013), coronary artery disease (p = .001) and chronic heart (p = .010) and kidney failure (p = .013) compared to patients in group 1. The survival of patients in group 2 and 3 was significantly poorer compared to the patients in group 1 (HR1.6, 95% CI 1.2-2.2, p = .002 and 1.7, 95% CI 1.2-2.3, p < .001, respectively). Overall and cardiovascular mortality was higher in groups 2 and 3 than group 1.39.5% of patients with incompressible ankle arteries (ABI ≥ 2.5) in both lower limbs had toe pressure (TP) <50 mmHg and a poorer survival compared to patients with a higher TP. CONCLUSIONS Patients with incompressible ankle arteries have significantly higher overall and cardiovascular mortality and a greater burden of disease compared to the patients with a measurable yet abnormally high ABI. TP is a useful diagnostic tool when ABI is immeasurably high. All patients with ABI > 1.3 should be considered as high cardiovascular risk patients.
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Affiliation(s)
- Mirjami Laivuori
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Finland
| | | | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Finland
| | - Harri Hakovirta
- Department of Surgery, University of Turku, Finland
- Department of Vascular Surgery, Turku University Hospital, Finland
- Department of Surgery, Satasairaala, Pori, Finland
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van Schilt KLJ, Hollander EJF, Koelemay MJ, van Geloven AAW, Olthof DC. Assessment of microcirculatory changes in local tissue oxygenation after revascularization for peripheral arterial disease with the Hyperview®, a portable hyperspectral imaging device. Vascular 2023; 31:961-967. [PMID: 35580351 DOI: 10.1177/17085381221102813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The Hyperview® is a hyperspectral camera, which can be used to assess the microcirculation of patients with peripheral arterial disease (PAD) and/or diabetes mellitus (DM). It measures local tissue oxygenation in concentrations of oxyhemoblobin (OXY), deoxyhemoglobin (DEOXY), and O2-saturation (O2-SAT) in arbitrary units. The aim of this validation study is to assess whether the Hyperview® is able to monitor microcirculatory changes after revascularization in patients with PAD. METHODS In this prospective observational cohort study, 50 patients with PAD were included who were scheduled for endovascular, hybrid, or open revascularization. The ankle-brachial index (ABI), systolic toe pressure (TP) (in case of DM), and a set of Hyperview® measurements of the plantar region were recorded before and after treatment. Changes in pre- and postoperative measurements were assessed with the paired t-test. RESULTS Some 38 patients underwent endovascular revascularization and eight patients underwent hybrid or open vascular surgical revascularization. After revascularization, the ABI improved from 0.58 to 0.80 (p < 0.001). OXY increased from 72.6 to 77.8 (p = 0.134). DEOXY decreased from 69.1 to 55.0 (p < 0.001). O2-SAT increased from 51.3 to 58.1 (p < 0.001). TP improved from 50.6 to 61.9 mmHg (p = 0.065) but was measured in only 16 patients. CONCLUSION The Hyperview® is able to observe changes in the microcirculation after revascularization in terms of DEOXY and O2-SAT. The results of this study are a promising step into the validation of the Hyperview®.
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Affiliation(s)
| | | | - Mark J Koelemay
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | | | - Dominique C Olthof
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
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Learned A, Robinson SA, Nguyen TT. Comprehensive Care of Lower-Extremity Wounds. Surg Clin North Am 2023; 103:745-765. [PMID: 37455035 DOI: 10.1016/j.suc.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
There are 5 common types of chronic nonhealing lower-extremity wounds: arterial, venous, diabetic foot ulcer, pressure, and mixed or atypical. Each chronic wound type has distinct features, and understanding the underlying cause will dictate the wound treatment plan. Here, the authors review the distinguishing wound properties for these 5 common chronic nonhealing lower-extremity wounds and outline a comprehensive treatment plan that addresses wound perfusion, debridement, infection control, moisture balance, and use of complementary advanced wound care products.
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Affiliation(s)
- Allison Learned
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
| | - Sudie-Ann Robinson
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
| | - Tammy T Nguyen
- Department of Surgery, Division of Vascular Surgery, University of Massachusetts Chan Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA; University of Massachusetts Diabetes Center of Excellence.
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Analysis of wound healing time and wound-free period in patients with chronic limb-threatening ischemia treated with and without revascularization. J Vasc Surg 2022; 76:1667-1673.e1. [PMID: 35810955 PMCID: PMC9925334 DOI: 10.1016/j.jvs.2022.05.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 04/11/2022] [Accepted: 05/03/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND The traditionally reported outcomes for patients with ischemic wounds have centered on amputation-free survival. However, that discounts the importance of other patient-centered outcomes such as the wound healing time (WHT) and wound-free period (WFP). We evaluated the long-term wound outcomes of patients treated for chronic limb-threatening ischemia at our institution. METHODS From 2014 to 2017, we identified all patients with chronic limb-threatening ischemia and ischemic wounds using symptomatic and hemodynamic criteria. The primary data included the wound size, wound location, WIfI (wound, ischemia, foot infection) grade, WHT, WFP, minor and major amputation, and death. Wounds were not considered healed if the patient had required a major amputation or had died before wound healing. The WHT was calculated as the interval in days between the diagnosis and determination of a healed wound. The WFP was calculated as the interval in days between a healed wound and wound recurrence, major amputation, death, or the end of the study period. A comparison of the wound healing parameters stratified by revascularization status was performed using the Student t test. A generalized linear model adjusted for age, sex, initial wound size, and WIfI grade was used to evaluate the risk of wound healing with and without revascularization. RESULTS A total of 256 patients had presented with 372 wounds. Of the 256 patients, 48% had undergone revascularization. During the study period, 97 minor amputations and 100 major amputations had been required, and 132 patients had died. The average wound size was 13.9 ± 52.0 cm2; however, for the 155 wounds that had healed, the average size was only 4.0 ± 9.6 cm2 (P = .002). No differences were found in the wound size when stratified by revascularization status (P = .727). Adjusted for the initial wound size, the risk of wound healing was not different when stratified by revascularization (risk ratio, 1.22; 95% confidence interval, 0.80-1.87; P = .354). For those whose wounds had healed, the average WHT and WFP were 173 ± 169 days and 775 ± 317 days, respectively. The WHT was not faster for the revascularized group (155 days vs 188 days; P = .221). When stratified by revascularization status, the rate of wound recurrence was 4.6 vs 8.9 wounds per 100 person-years for the revascularized and nonrevascularized groups, respectively (P = .125). CONCLUSIONS In our study, we found that, except for patients who presented with severe ischemia, revascularization was not associated with improved rates of wound healing. Among the wounds that healed, regardless of the initial ischemia grade, revascularization was not associated with a faster WHT or longer WFPs.
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Kwan TW, Lee S, Lin P, Liou M, Siu H, Patel A, Ruzsa Z. Tibio-pedal arterial pressure assessment during endovascular intervention to improve quality-of-life in patients with intermittent claudication. Front Cardiovasc Med 2022; 9:1038353. [DOI: 10.3389/fcvm.2022.1038353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 11/15/2022] [Indexed: 11/30/2022] Open
Abstract
ObjectiveThe aim of this study is to compare the quality-of-life (QOL) outcomes and the tibio-pedal arterial pressure post-endovascular intervention.BackgroundPhysiological assessment of peripheral arterial lesions is infrequently performed during endovascular interventions.Materials and methodsWe retrospectively reviewed all 343 patients with intermittent claudication who underwent an endovascular intervention via tibio-pedal artery access from October 2018 to May 2021. The baseline and post-intervention tibio-pedal arterial pressures from the pedal sheaths were measured. QOL was assessed using a pre-validated Walking Impairment Questionnaire (WIQ) score before and at 30-day after intervention. We compared the baseline tibio-pedal arterial pressure, post-intervention tibio-pedal arterial pressure, delta pressure (post-intervention minus baseline), baseline WIQ scores, 30-day WIQ scores, and delta score (30-day minus baseline).ResultsAll 343 patients had successful tibio-pedal accesses. The average tibio-pedal arterial pressure at baseline was 87.0 ± 1.8 mmHg vs. 135.5 ± 1.7 mmHg post-intervention (p < 0.001). Average baseline and 30-day WIQ scores were summation (99.8 ± 3.3 vs. 115.0 ± 3.1, p < 0.001), walking distance (35.7 ± 1.3 vs. 42.5 ± 1.3, p < 0.001), walking speed (21.1 ± 0.9 vs. 23.6 ± 0.8, p = 0.036), stair climbing (4.7 ± 1.4 vs. 24.2 ± 1.4, p = 0.019), and symptoms (18.8 ± 0.2 vs. 20.1 ± 0.2, p < 0.001), respectively. When comparing the increased post-intervention tibio-pedal arterial pressure <60 mmHg vs. ≥60 mmHg, the average delta WIQ scores were all significantly improved with summation (10.0 ± 3.9 to 25.8 ± 5.5, p = 0.01), walking distance (4.1 ± 1.7 to 9.8 ± 2.5, p = 0.02), walking speed (1.5 ± 1.1 to 4.3 ± 1.5, p = 0.02), stair climbing (2.3 ± 1.8 to 9.4 ± 2.5, p = 0.02), and symptoms (1.0 ± 0.3 to 1.8 ± 0.4, p = 0.04), respectively.ConclusionIncreasing the post-intervention tibio-pedal arterial pressure by 60 mmHg can enhance QOL as suggested by improvement of WIQ scores.
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Ichihashi S, Fujimura N, Utsunomiya M, Bolstad F, Nakai T, Iwakoshi S, Tanaka T. Hemodynamic evaluation of lower limbs in patients with chronic limb-threatening ischemia. Cardiovasc Interv Ther 2022; 37:635-640. [PMID: 35941316 DOI: 10.1007/s12928-022-00883-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 11/29/2022]
Abstract
Revascularization plays an important role in the treatment of chronic limb-threatening ischemia. Evaluation of hemodynamic compromise in the lower extremity is required to optimize the treatment strategy for each patient. A variety of methods have been reported to detect arterial obstruction or impaired foot perfusion. This article reviews each method, clarifying features and limitations.
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Affiliation(s)
- Shigeo Ichihashi
- Department of Diagnostic and Interventional Radiology, Nara Medical University, 840 Shijyocho, Kashihara, Nara, 634-8521, Japan.
| | - Naoki Fujimura
- Division of Vascular Surgery, Saiseikai Central Hospital, Tokyo, Japan
| | - Makoto Utsunomiya
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan.,TOWN Homecare Clinic, Tokyo, Japan
| | - Francesco Bolstad
- Department of Clinical English, Nara Medical University, Nara, Japan
| | - Takahiro Nakai
- Department of Diagnostic and Interventional Radiology, Nara Medical University, 840 Shijyocho, Kashihara, Nara, 634-8521, Japan
| | - Shinichi Iwakoshi
- Department of Diagnostic and Interventional Radiology, Nara Medical University, 840 Shijyocho, Kashihara, Nara, 634-8521, Japan
| | - Toshihiro Tanaka
- Department of Diagnostic and Interventional Radiology, Nara Medical University, 840 Shijyocho, Kashihara, Nara, 634-8521, Japan
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El Khoury R, Wu B, Kupiec-Weglinski SA, Liu IH, Edwards CT, Lancaster EM, Hiramoto JS, Vartanian SM, Schneider PA, Conte MS. Limb-based patency as a measure of effective revascularization for chronic limb-threatening ischemia. J Vasc Surg 2022; 76:997-1005.e2. [PMID: 35697305 DOI: 10.1016/j.jvs.2022.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/12/2022] [Accepted: 04/24/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE In 2019, the Global Vascular Guidelines on chronic limb-threatening ischemia (CLTI) introduced the concept of limb-based patency (LBP) defined as maintained patency of a target artery pathway (TAP) following intervention. The purpose of this study was to investigate the relationship between LBP and major adverse limb events following infrainguinal revascularization for CLTI. METHODS Consecutive patients undergoing revascularization for CLTI between 2016 and 2019 at a single tertiary institution with a dedicated limb preservation team were included. Subjects with aorto-iliac disease, prior infrainguinal stents or existing bypass grafts were excluded. Demographics, Global Limb Anatomic Staging System (GLASS) scores, Wound, Ischemia, foot Infection (WIfI) stages, revascularization details, and limb-specific outcomes were reviewed. LBP was defined by the absence of re-intervention, occlusion, critical stenosis (>70%), or hemodynamic compromise with ongoing symptoms of CLTI. Major adverse limb events (MALE) included thrombectomy or thrombolysis, new bypass, open surgical graft revision and/or major amputation. RESULTS 184 unique limbs in 163 patients were analyzed. This cohort was composed of 66.9% male patients with a mean age of 72. Baseline characteristics included diabetes (66%), tissue loss (91%) and advanced WIfI stages (30% stage 3, 51% stage 4). GLASS stage 3 anatomic patterns were common (n=119; 65%). 60 limbs were treated with open bypass (65% involving tibial targets) while 124 underwent endovascular intervention (70% including infrapopliteal targets). 12-month freedom from MALE and loss of LBP were 74.0%±3.7% and 48.6%±4.2%, respectively. Diabetes (HR=2.56 [1.13-5.83]; p=.025) and loss of LBP (4.12 [1.96-8.64]; p<.001) were independent predictors of MALE in a Cox proportional hazard model. Loss of LBP was the sole independent predictor of major limb amputation after revascularization (HR=4.97 [1.89-13.09]; p=.001). Loss of LBP impacted both intermediate-risk limbs (HR=2.85 [1.02-7.97]; p=.047 in WIfI stages 1-3) and high-risk limbs (HR=3.99 [1.32-12.11]; p=.014 in WIfI stage 4). However, loss of LBP had the greatest impact on patients presenting with WIfI stage 4 disease (31% vs. 8% major limb amputation at 12-months in limbs without vs. with maintained LBP). CONCLUSIONS Anatomic durability of revascularization, as measured by LBP, is a key determinant of treatment outcomes in CLTI regardless of the initial mode of intervention undertaken. Loss of LBP is most detrimental in patients presenting with advanced limb threat (WIfI stage 4).
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Affiliation(s)
- Rym El Khoury
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Bian Wu
- Department of Surgery, Division of Vascular Surgery, Kaiser Permanente San Francisco Medical Center, CA
| | | | - Iris H Liu
- School of Medicine, University of California San Francisco, CA
| | - Ceazon T Edwards
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Elizabeth M Lancaster
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Jade S Hiramoto
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Shant M Vartanian
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Peter A Schneider
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA
| | - Michael S Conte
- Department of Surgery, Division of Vascular Surgery, University of California San Francisco, CA.
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Ryan TE, Kim K, Scali ST, Berceli SA, Thome T, Salyers ZR, O'Malley KA, Green TD, Karnekar R, Fisher‐Wellman KH, Yamaguchi DJ, McClung JM. Interventional- and amputation-stage muscle proteomes in the chronically threatened ischemic limb. Clin Transl Med 2022; 12:e658. [PMID: 35073463 PMCID: PMC8785983 DOI: 10.1002/ctm2.658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 11/05/2021] [Accepted: 11/11/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Despite improved surgical approaches for chronic limb-threatening ischemia (CLTI), amputation rates remain high and contributing tissue-level factors remain unknown. The purpose of this study was twofold: (1) to identify differences between the healthy adult and CLTI limb muscle proteome, and (2) to identify differences in the limb muscle proteome of CLTI patients prior to surgical intervention or at the time of amputation. METHODS AND RESULTS Gastrocnemius muscle was collected from non-ischemic controls (n = 19) and either pre-interventional surgery (n = 10) or at amputation outcome (n = 29) CLTI patients. All samples were subjected to isobaric tandem-mass-tag-assisted proteomics. The mitochondrion was the primary classification of downregulated proteins (> 70%) in CLTI limb muscles and paralleled robust functional mitochondrial impairment. Upregulated proteins (> 38%) were largely from the extracellular matrix. Across the two independent sites, 39 proteins were downregulated and 12 upregulated uniformly. Pre-interventional CLTI muscles revealed a robust upregulation of mitochondrial proteins but modest functional impairments in fatty acid oxidation as compared with controls. Comparison of pre-intervention and amputation CLTI limb muscles revealed mitochondrial proteome and functional deficits similar to that between amputation and non-ischemic controls. Interestingly, these observed changes occurred despite 62% of the amputation CLTI patients having undergone a prior surgical intervention. CONCLUSIONS The CLTI proteome supports failing mitochondria as a phenotype that is unique to amputation outcomes. The signature of pre-intervention CLTI muscle reveals stable mitochondrial protein abundance that is insufficient to uniformly prevent functional impairments. Taken together, these findings support the need for future longitudinal investigations aimed to determine whether mitochondrial failure is causally involved in amputation outcomes from CLTI.
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Affiliation(s)
- Terence E. Ryan
- Department of Applied Physiology and KinesiologyUniversity of FloridaGainesvilleFloridaUSA
- Center for Exercise ScienceUniversity of FloridaGainesvilleFloridaUSA
- Myology InstituteUniversity of FloridaGainesvilleFloridaUSA
| | - Kyoungrae Kim
- Department of Applied Physiology and KinesiologyUniversity of FloridaGainesvilleFloridaUSA
| | - Salvatore T. Scali
- Division of Vascular Surgery and Endovascular TherapyUniversity of FloridaGainesvilleFloridaUSA
- Malcom Randall Veteran Affairs Medical CenterGainesvilleFloridaUSA
| | - Scott A. Berceli
- Division of Vascular Surgery and Endovascular TherapyUniversity of FloridaGainesvilleFloridaUSA
- Malcom Randall Veteran Affairs Medical CenterGainesvilleFloridaUSA
| | - Trace Thome
- Department of Applied Physiology and KinesiologyUniversity of FloridaGainesvilleFloridaUSA
| | - Zachary R. Salyers
- Department of Applied Physiology and KinesiologyUniversity of FloridaGainesvilleFloridaUSA
| | - Kerri A. O'Malley
- Division of Vascular Surgery and Endovascular TherapyUniversity of FloridaGainesvilleFloridaUSA
- Malcom Randall Veteran Affairs Medical CenterGainesvilleFloridaUSA
| | - Thomas D. Green
- Department of PhysiologyBrody School of MedicineEast Carolina UniversityGreenvilleNorth CarolinaUSA
- East Carolina Diabetes and Obesity InstituteEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Reema Karnekar
- Department of PhysiologyBrody School of MedicineEast Carolina UniversityGreenvilleNorth CarolinaUSA
- East Carolina Diabetes and Obesity InstituteEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Kelsey H. Fisher‐Wellman
- Department of PhysiologyBrody School of MedicineEast Carolina UniversityGreenvilleNorth CarolinaUSA
- East Carolina Diabetes and Obesity InstituteEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Dean J. Yamaguchi
- Department of Cardiovascular ScienceEast Carolina UniversityGreenvilleNorth CarolinaUSA
- Division of SurgeryEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Joseph M. McClung
- Department of PhysiologyBrody School of MedicineEast Carolina UniversityGreenvilleNorth CarolinaUSA
- East Carolina Diabetes and Obesity InstituteEast Carolina UniversityGreenvilleNorth CarolinaUSA
- Department of Cardiovascular ScienceEast Carolina UniversityGreenvilleNorth CarolinaUSA
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12
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Toe pressure and toe brachial index are predictive of cardiovascular mortality regardless of the most diseased arterial segment in symptomatic lower-extremity artery disease-A retrospective cohort study. PLoS One 2021; 16:e0259122. [PMID: 34780498 PMCID: PMC8592499 DOI: 10.1371/journal.pone.0259122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/12/2021] [Indexed: 12/24/2022] Open
Abstract
Objective Although lower extremity arterial disease (LEAD) is most often multisegmental, the predominant disease location and risk factors differ between patients. Ankle-brachial index (ABI), toe-brachial index (TBI), and toe pressure (TP) are predictive of outcome in LEAD patients. Previously, we reported a classification method defining the most diseased arterial segment (MDAS); crural (CR), femoropopliteal (FP), or aortoiliac (AOI). Current study aimed to analyze the associations between MDAS, peripheral pressure measurements and cardiovascular mortality. Materials and methods We reviewed retrospectively 729 consecutive LEAD patients (Rutherford 2–6) who underwent digital subtraction angiography between January, 2009 to August, 2011 and had standardized peripheral pressure measurements. Results In Cox Regression analyses, cardiovascular mortality was associated with MDAS and non-invasive pressure indices as follows; MDAS AOI, TP <30 mmHg (HR 3.00, 95% CI 1.13–7.99); MDAS FP, TP <30 mmHg (HR 2.31, 95% CI 1.36–3.94), TBI <0.25 (HR 3.20, 95% CI 1.34–7.63), ABI <0.25 (HR 5.45, 95% CI 1.56–19.0) and ≥1.30 (HR 6.71, 95% CI 1.89–23.8), and MDAS CR, TP <30 mmHg (HR 4.26, 95% CI 2.19–8.27), TBI <0.25 (HR 7.71, 95% CI 1.86–32.9), and ABI <0.25 (HR 2.59, 95% CI 1.15–5.85). Conclusions Symptomatic LEAD appears to be multisegmental with severe infrapopliteal involvement. Because of this, TP and TBI are strongly predictive of cardiovascular mortality and they should be routinely measured despite the predominant disease location or clinical presentation.
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13
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Alexandrescu VA, Brochier S, Schoenen S, Antonelli E, Azdad K, Zekhnini I, Nodit M. Grades of Below-the-Ankle Arterial Occlusive Disease following the Angiosome Perfusion: A New Morphological Assessment and Correlations with the Inframalleolar GVG Stratification in CLTI Patients. Ann Vasc Surg 2021; 81:358-377. [PMID: 34780951 DOI: 10.1016/j.avsg.2021.09.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/11/2021] [Accepted: 09/13/2021] [Indexed: 01/15/2023]
Abstract
PURPOSE To assess a specific classification of the foot atherosclerotic disease concerning the angiosomal source arteries, the connected foot arches and attached collaterals for Rutherford 5, CLTI patients. To compare eventual analogies of this novel grading system with previously reported GLASS/GVG inframalleolar patterns of occlusive disease (P0-P2). MATERIALS AND METHODS A series of 336 ischemic feet (221 diabetics) were selected and retrospectively analyzed. For each angiographic pattern of inframalleolar atherosclerotic disease, 4 severity classes of targeted angiosomal artery path (TAAP), associating 4 other classes concerning linked foot arches (LFA) and collaterals occlusive disease were described. By associating the 4 TAAP with the 4 others parallel LFA and collaterals classes, 4 novel anatomical "Grades" (A-D) of occlusive disease were described. Limb salvage was studied between groups of diabetic and non-diabetic patients. RESULTS Using a primary endovascular approach, limb preservation comparison of grade A/B proved without significance for diabetics (P = 0.032) and non-diabetics (P = 0.226). Comparison in diabetics and/or non-diabetics between A/C (P = 0.045 and 0.046), A/D (P = 0.027 and 0.030, B/C (P = 0.009 and 0.038), and B/D (P = 0.006 and P = 0.042), as well as C/D groups (P = 0.048 and P = 0.034) proved ponderous. Parallel analysis of similar grades (A/A, B/B, etc.) with, or without diabetes appeared without significance (P > 0.05). Further comparison between grades A+B (assigned as P0/GVG), versus C (P1), and D (P2), proved significant (P < 0.0001). CONCLUSION The present grading system proposes a useful correlation between the severity of foot angiosomal arteries, arches, and collaterals disease and limb salvage, confirming the clinical significance of P0-P2 GVG severity score. This analysis also points the limits of EVT to be probably avoided in grade D patients.
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Affiliation(s)
- Vlad Adrian Alexandrescu
- Department of Vascular and Thoracic Surgery, Princess Paola Hospital Marche-en-Famenne, IFAC/Vivalia, Marche-en-Famenne, Belgium.
| | - Sophie Brochier
- Department of Diabetology, Princess Paola Hospital Marche-en-Famenne, IFAC/Vivalia, Marche-en-Famenne, Belgium.
| | - Sophie Schoenen
- Department of Vascular and Thoracic Surgery, Princess Paola Hospital Marche-en-Famenne, IFAC/Vivalia, Marche-en-Famenne, Belgium.
| | - Elisa Antonelli
- Department of Vascular and Thoracic Surgery, Princess Paola Hospital Marche-en-Famenne, IFAC/Vivalia, Marche-en-Famenne, Belgium.
| | - Khalid Azdad
- Department of Radiology, Princess Paola Hospital Marche-en-Famenne, IFAC/Vivalia, Marche-en-Famenne, Belgium.
| | - Ines Zekhnini
- Department of Vascular and Thoracic Surgery, Princess Paola Hospital Marche-en-Famenne, IFAC/Vivalia, Marche-en-Famenne, Belgium.
| | - Mihaela Nodit
- Department of Geriatric care, Princess Paola Hospital Marche-en-Famenne, IFAC/Vivalia, Marche-en-Famenne, Belgium.
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14
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The Society for Vascular Surgery Objective Performance Goals for Critical Limb Ischemia are attainable in select patients with ischemic wounds managed with wound care alone. Ann Vasc Surg 2021; 78:28-35. [PMID: 34543715 DOI: 10.1016/j.avsg.2021.06.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/28/2021] [Accepted: 06/30/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND To set therapeutic benchmarks, in 2009 the Society for Vascular Surgery defined objective performance goals (OPG) for treatment of patients with chronic limb threatening ischemia (CLTI) with either open surgical bypass or endovascular intervention. The goal of these OPGs are to set standards of care from a revascularization standpoint and to provide performance benchmarks for 1 year patency rates for new endovascular therapies. While OPGs are useful in this regard, a critical decision point in the treatment of patients with CLTI is determining when revascularization is necessary. There is little guidance in the comprehensive treatment of this patient population, especially in the nonoperative cohort. Guidelines are needed for the CLTI patient population as a whole and not just those revascularized, and our aim was to assess whether CLTI OPGs could be attained with nonoperative management alone. METHODS Our cohort included patients with an incident diagnosis of CLTI (by hemodynamic and symptomatic criteria) at our institution from 2013-2017. The primary outcome measured was mortality. Secondary outcomes were limb loss and failure of amputation-free survival. Descriptive statistics were used to define the 2 groups - patients undergoing primary revascularization and patients undergoing primary wound management. The risk difference in outcomes between the 2 groups was estimated using collaborative-targeted maximum likelihood estimation. RESULTS Our cohort included 349 incident CLTI patients; 60% male, 51% white, mean age 63 +/- 13 years, 20% Rutherford 4, and 80% Rutherford 5. Most patients (277, 79%) underwent primary revascularization, and 72 (21%) were treated with wound care alone. Demographics and presenting characteristics were similar between groups. Although the revascularized patients were more likely to have femoropopliteal disease (72% vs. 36%), both groups had a high rate of infrapopliteal disease (62% vs. 57%). Not surprisingly, the patients in the revascularization group were less likely to have congestive heart failure (34% vs. 42%), complicated diabetes (52% vs. 79%), obesity (19% vs. 33%), and end stage renal disease (14% vs. 28%). In the wound care group, 2-year outcomes were 65% survival, 51% amputation free survival, 19% major limb amputation, and 17% major adverse cardiac event. The wound care cohort had a 13% greater risk of death at 2 years; however, the risk of limb loss at 2 years was 12% less in the wound care cohort. CONCLUSIONS A comprehensive set treatment goals and expected amputation free survival outcomes can guide revascularization, but also assure that appropriate outcomes are achieved for patients treated without revascularization. The 2-year outcomes achieved in this cohort provide an estimate of outcomes for nonrevascularized CLTI patients. Although multi-center or prospective studies are needed, we demonstrate that equal, even improved, limb salvage rates are possible.
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15
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Laivuori M, Hakovirta H, Kauhanen P, Sinisalo J, Sund R, Albäck A, Venermo M. Toe pressure should be part of a vascular surgeon's first-line investigation in the assessment of lower extremity artery disease and cardiovascular risk of a patient. J Vasc Surg 2020; 73:641-649.e3. [PMID: 32712345 DOI: 10.1016/j.jvs.2020.06.104] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 06/12/2020] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Toe pressure (TP) is an accurate indicator of the peripheral vascular status of a patient and thus cardiovascular risk, with less susceptibility to errors than ankle-brachial index (ABI). This study aimed to analyze how ABI and TP measurements associate with overall survival and cardiovascular death and to analyze the TP of patients with ABI of 0.9 to 1.3. METHODS The first ABI and TP measurements of a consecutive 6784 patients treated at the Helsinki University Hospital vascular surgery clinic between 1990 and 2009 were analyzed. Helsinki University Vascular Registry and the national Cause of Death Registry provided the data. RESULTS The poorest survival was in patients with ABI >1.3 (10-year survival, 15.3%; hazard ratio, 2.2; 95% confidence interval, 1.9-2.6; P < .0001; reference group, ABI 0.9-1.3), followed by the patients with TP <30 mm Hg (10-year survival, 19.6%; hazard ratio, 2.0; 95% confidence interval, 1.7-2.2; P < .0001; reference group, TP ≥80 mm Hg). The best 10-year survival was in patients with TP ≥80 mm Hg (43.9%). Of the 642 patients with normal ABI (0.9-1.3), 18.7% had a TP <50 mm Hg. The highest cardiovascular death rate (64.6%) was in the patients with TP <30 mm Hg, and it was significantly lower than for the patients with TP >50 mm Hg. CONCLUSIONS Low TP is associated significantly with survival and cardiovascular mortality. Patients with a normal ABI may have lower extremity artery disease (LEAD) and a considerable risk for a cardiovascular event. If only the ABI is measured in addition to clinical examination, a substantial proportion of patients may be left without LEAD diagnosis or adequate treatment of cardiovascular risk factors. Thus, especially if ABI is normal, LEAD is excluded only if TPs are also measured and are normal.
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Affiliation(s)
- Mirjami Laivuori
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Harri Hakovirta
- Department of Vascular Surgery, Turku University Hospital and University of Turku, Turku, Finland
| | - Petteri Kauhanen
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Juha Sinisalo
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Reijo Sund
- Institute of Clinical Medicine, Surgery, Kuopio Musculoskeletal Research Unit, University of Eastern Finland, Kuopio, Finland
| | - Anders Albäck
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
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16
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Serra R, Bracale UM, Barbetta A, Ielapi N, Licastro N, Gallo A, Fregola S, Turchino D, Gasbarro V, Mastroroberto P, de Franciscis S. PredyCLU: A prediction system for chronic leg ulcers based on fuzzy logic; part II-Exploring the arterial side. Int Wound J 2020; 17:987-991. [PMID: 32285613 DOI: 10.1111/iwj.13360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/17/2020] [Accepted: 03/20/2020] [Indexed: 11/27/2022] Open
Abstract
Peripheral arterial disease (PAD) and its most severe form, critical limb ischaemia (CLI), are very common clinical conditions related to atherosclerosis and represent the major causes of morbidity, mortality, disability, and reduced quality of life (QoL), especially for the onset of ischaemic chronic leg ulcers (ICLUs) and the subsequent need of amputation in affected patients. Early identification of patients at risk of developing ICLUs may represent the best form of prevention and appropriate management. In this study, we used a Prediction System for Chronic Leg Ulcers (PredyCLU) based on fuzzy logic applied to patients with PAD. The patient population consisted of 80 patients with PAD, of which 40 patients (30 males [75%] and 10 females [25%]; mean age 66.18 years; median age 67.50 years) had ICLUs and represented the case group. Forty patients (100%) (27 males [67.50%] and 13 females [32.50%]; mean age 66.43 years; median age 66.50 years) did not have ICLUs and represented the control group. In patients of the case group, the higher was the risk calculated with the PredyCLU the more severe were the clinical manifestations recorded. In this study, the PredyCLU algorithm was retrospectively applied on a multicentre population of 80 patients with PAD. The PredyCLU algorithm provided a reliable risk score for the risk of ICLUs in patients with PAD.
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Affiliation(s)
- Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Umberto M Bracale
- Department of Public Health, University of Naples "Federico II", Naples, Italy
| | - Andrea Barbetta
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Nicola Ielapi
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy.,Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Noemi Licastro
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Alessandro Gallo
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Salvatore Fregola
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Davide Turchino
- Department of Public Health, University of Naples "Federico II", Naples, Italy
| | - Vincenzo Gasbarro
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Pasquale Mastroroberto
- Department of Experimental and Clinical Medicine, University of Catanzaro, Catanzaro, Italy
| | - Stefano de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
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17
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Alexandrescu VA, Brochier S, Limgba A, Balthazar S, Khelifa H, De Vreese P, Azdad K, Nodit M, Pottier M, Van Espen D, Sinatra T. Healing of Diabetic Neuroischemic Foot Wounds With vs Without Wound-Targeted Revascularization: Preliminary Observations From an 8-Year Prospective Dual-Center Registry. J Endovasc Ther 2019; 27:20-30. [PMID: 31709886 DOI: 10.1177/1526602819885131] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Purpose: To assess the clinical efficacy of endovascular angiosome-oriented wound-targeted revascularization (WTR) vs indirect (wound-indifferent) revascularization (IR) in diabetic patients with neuroischemic foot ulcers. Materials and Methods: Between April 2009 and July 2017, 167 diabetic patients (mean age 72.8 years; 137 men) with chronic limb-threatening ischemia (Rutherford category 5) and foot wounds (Wagner 2-4) in 194 limbs were prospectively registered and scheduled for primary infragenicular endovascular treatment. Specific angiosome source artery reperfusion sustained by patent foot arches or arterial-arterial connections was attempted initially. If this approach failed, topographic revascularization via available collaterals (WTRc) and IR were sequentially attempted. Results: Reperfusion was successful in 176 (91%) of 194 limbs (113 with WTR, 28 with WTRc, and 35 with IR); the global angiosome-oriented technical success (WTR and WTRc) was 73% (141/194). The mean follow-up was 10.9±0.7 months (range 3-12.5). Over 1 year, 102 (58%) of the 176 successfully treated limbs experienced wound healing [79/113 (70%) in the WTR group, 15/28 (54%) in the WTRc group, and 7/35 (20%) in the IR group; p=0.011]. The mean time to healing was 6.8±0.4 months in the WTR group, 7.9±0.6 months in the WTRc group, and 9.8±0.7 months in the IR group (p=0.001). Relapses were noted in 18 (16%) WTR limbs, 5 (18%) WTRc limbs, and 6 (17%) IR limbs. Comparison between WTR and IR and WTRc vs IR showed improved cicatrization in the angiosome-oriented groups (p<0.05). Major adverse limb events (MALE) and limb salvage were different between WTR and WTRc and between WTR and IR groups (p<0.05), while WTRc vs IR was not. Amputation-free survival was not influenced by the revascularization strategy (p=0.093). Conclusion: Wound healing in diabetic patients with chronic limb-threatening ischemia appeared to be improved by intentional wound-targeted revascularization, but no uniform benefit concerning MALE or limb preservation was observed. IR still represents an alternative for limb salvage in cases in which angiosome-guided revascularization fails.
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Affiliation(s)
| | - Sophie Brochier
- Department of Diabetology, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Augustin Limgba
- Department of Surgery, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Severine Balthazar
- Department of Anesthesiology, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Hafid Khelifa
- Department of Intensive Care, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Pierrick De Vreese
- Department of Anesthesiology, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Khalid Azdad
- Department of Radiology, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Mihaela Nodit
- Department of Geriatric Care, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Morgane Pottier
- Department of Surgery, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Didier Van Espen
- Department of Orthopedic Surgery, Princess Paola Hospital, Marche-en-Famenne, Belgium
| | - Tommy Sinatra
- Department of Surgery, Princess Paola Hospital, Marche-en-Famenne, Belgium
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18
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Kwan TW, Parikh S, Patel A, Htun WW, Shah S, Huang Y, Liou M, Ruzsa Z. Functional hemodynamics assessment during endovascular Tibio-pedal retrograde intervention of peripheral arterial disease. Catheter Cardiovasc Interv 2019; 94:256-263. [PMID: 31094088 DOI: 10.1002/ccd.28337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 04/04/2019] [Accepted: 04/30/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE We sought to use a novel technique to measure the functional hemodynamics of peripheral arterial lesions during endovascular interventions. BACKGROUND Functional hemodynamics has not been thoroughly evaluated during endovascular interventions. The aim of our study is to evaluate the feasibility and the potential benefits of pedal pressures measurements from tibio-pedal access. METHODS We retrospectively reviewed 100 consecutive patients who underwent endovascular interventions via tibio-pedal artery access between October 3, 2018 and December 15, 2018. Baseline and postintervention pedal pressures from the pedal sheaths were measured. We also evaluated the pedal-brachial index (PBI) which is defined as the pedal sheath pressure divided by the simultaneously brachial cuff pressure. We compared baseline pedal pressures, postintervention pedal pressures, baseline PBI, postintervention PBI, % change of PBI ([postintervention PBI minus baseline PBI]/baseline PBI), and resting ankle-brachial index (ABI) versus baseline PBI in this cohort of patients. RESULTS All 100 patients had successful tibio-pedal artery access. Baseline pedal pressure was 70 + 30 mmHg with post intervention pedal pressure of 133 + 27 mmHg (p < .001). Baseline PBI was 0.75 + 0.24 with post intervention PBI of 1.09 + 0.19 (p < .001). The correlation coefficient of resting ABI vs. baseline PBI was 0.55. The % change of PBI was 63.2 + 52.4%. There was significant improvement of postintervention PBI when compared to baseline PBI in the majority of patients. CONCLUSIONS Obtaining pedal pressures and PBI from tibio-pedal access can be a feasible tool for endovascular interventions. This simple technique can provide us important functional hemodynamics information before and after peripheral revascularization.
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Affiliation(s)
- Tak W Kwan
- Department of Cardiology, Mount Sinai Beth Israel, New York, New York.,Department of Cardiology, Mount Sinai West, New York, New York.,Department of Cardiology, Chinatown Cardiology, PC, New York, New York
| | - Sahil Parikh
- Department of Cardiology, Columbia University Medical Center, New York, New York
| | - Apurva Patel
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Wah Wah Htun
- Department of Cardiology, Mount Sinai Beth Israel, New York, New York.,Department of Cardiology, Chinatown Cardiology, PC, New York, New York
| | - Sooraj Shah
- Department of Cardiology, Mount Sinai Beth Israel, New York, New York.,Department of Cardiology, Mount Sinai West, New York, New York.,Department of Cardiology, Chinatown Cardiology, PC, New York, New York
| | - Yili Huang
- Department of Cardiology, Mount Sinai Beth Israel, New York, New York.,Department of Cardiology, Chinatown Cardiology, PC, New York, New York
| | - Michael Liou
- Department of Cardiology, Mount Sinai Beth Israel, New York, New York.,Department of Cardiology, Chinatown Cardiology, PC, New York, New York
| | - Zoltan Ruzsa
- Department of Cardiology, Semmelweis University, Budapest, Hungary
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19
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Shishehbor MH, Rundback J, Bunte M, Hammad TA, Miller L, Patel PD, Sadanandan S, Fitzgerald M, Pastore J, Kashyap V, Henry TD. SDF-1 plasmid treatment for patients with peripheral artery disease (STOP-PAD): Randomized, double-blind, placebo-controlled clinical trial. Vasc Med 2019; 24:200-207. [DOI: 10.1177/1358863x18817610] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The efficacy of biologic therapies in critical limb ischemia (CLI) remains elusive, in part, due to limitations in trial design and patient selection. Using a novel design, we examined the impact of complementing revascularization therapy with intramuscular JVS-100 – a non-viral gene therapy that activates endogenous regenerative repair pathways. In this double-blind, placebo-controlled, Phase 2B trial, we randomized 109 patients with CLI (Rutherford class V or VI) to 8 mg or 16 mg intramuscular injections of placebo versus JVS-100. Patients were eligible if they persistently had reduced forefoot perfusion, by toe–brachial index (TBI) or skin perfusion pressure (SPP), following successful revascularization with angiographic demonstration of tibial arterial flow to the ankle. The primary efficacy end point was a 3-month wound healing score assessed by an independent wound core laboratory. The primary safety end point was major adverse limb events (MALE). Patients’ mean age was 71 years, 33% were women, 79% had diabetes, and 8% had end-stage renal disease. TBI after revascularization was 0.26, 0.27, and 0.26 among the three groups (placebo, 8 mg, and 16 mg injections, respectively). Only 26% of wounds completely healed at 3 months, without any differences between the three groups (26.5%, 26.5%, and 25%, respectively). Similarly, there were no significant changes in TBI at 3 months. Three (2.8%) patients died and two (1.8%) had major amputations. Rates of MALE at 3 months were 8.8%, 20%, and 8.3%, respectively. While safe, JVS-100 failed to improve wound healing or hemodynamic measures at 3 months. Only one-quarter of CLI wounds healed at 3 months despite successful revascularization, highlighting the need for additional research in therapies that can improve microcirculation in these patients. ClinicalTrials.gov Identifier: NCT02544204
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Affiliation(s)
- Mehdi H Shishehbor
- Harrington Heart & Vascular Institute, Vascular Center, University Hospitals, Cleveland, OH, USA
| | - John Rundback
- Interventional Institute, Holy Name Medical Center, Teaneck, NJ, USA
| | - Matthew Bunte
- Department of Cardiology, Saint Luke’s Health Systems, Kansas City, MO, USA
| | - Tarek A Hammad
- Department of Medicine, Division of Cardiology, University of Texas Health at San Antonio, San Antonio, TX, USA
| | - Leslie Miller
- Department of Cardiology, Morton Plant Hospital, Clearwater, FL, USA
| | - Parag D Patel
- Department of Cardiology, Morton Plant Hospital, Clearwater, FL, USA
| | | | - Michael Fitzgerald
- Department of Clinical Product Development, Juventas Therapeutics, Cleveland, OH, USA
| | - Joseph Pastore
- Department of Clinical Product Development, Juventas Therapeutics, Cleveland, OH, USA
| | - Vikram Kashyap
- Harrington Heart & Vascular Institute, Vascular Center, University Hospitals, Cleveland, OH, USA
| | - Timothy D Henry
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Kovacs D, Csiszar B, Biro K, Koltai K, Endrei D, Juricskay I, Sandor B, Praksch D, Toth K, Kesmarky G. Toe-brachial index and exercise test can improve the exploration of peripheral artery disease. Atherosclerosis 2018; 269:151-158. [DOI: 10.1016/j.atherosclerosis.2018.01.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 12/11/2017] [Accepted: 01/12/2018] [Indexed: 10/18/2022]
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Settembre N, Kagayama T, Kauhanen P, Vikatmaa P, Inoue Y, Venermo M. The Influence of Heating on Toe pressure in Patients with Peripheral Arterial Disease. Scand J Surg 2017; 107:62-67. [PMID: 28516802 DOI: 10.1177/1457496917705994] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIM The toe skin temperature in vascular patients can be low, making reliable toe pressure measurements difficult to obtain. The aim of this study was to evaluate the effect of heating on the toe pressure measurements. MATERIALS AND METHODS A total of 86 legs were examined. Brachial pressure and toe pressure were measured at rest in a supine position using a laser Doppler device that also measured skin temperature. After heating the toes for 5 min with a heating pad, we re-measured the toe pressure. Furthermore, after heating the skin to 40° with the probe, toe pressures were measured a third time. RESULTS The mean toe skin temperature at the baseline measurement was 24.0 °C (standard deviation: 2.8). After heating the toes for 5 min with a warm heating pad, the skin temperature rose to a mean 27.8 °C (standard deviation: 2.8; p = 0.000). The mean toe pressure rose from 58.5 (standard deviation: 32) to 62 (standard deviation: 32) mmHg (p = 0.029). Furthermore, after the skin was heated up to 40 °C with the probe, the mean toe pressure in the third measurement was 71 (standard deviation: 34) mmHg (p = 0.000). The response to the heating varied greatly between the patients after the first heating-from -34 mmHg (toe pressure decreased from 74 to 40 mmHg) to +91 mmHg. When the toes were heated to 40 °C, the change in to toe pressure from the baseline varied between -28 and +103 mmHg. CONCLUSION Our data indicate that there is a different response to the heating in different clinical situations and in patients with a different comorbidity.
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Affiliation(s)
- N Settembre
- 1 Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - T Kagayama
- 1 Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,2 Department of Vascular and Applied Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - P Kauhanen
- 1 Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - P Vikatmaa
- 1 Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Y Inoue
- 2 Department of Vascular and Applied Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - M Venermo
- 1 Department of Vascular Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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22
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Freisinger E, Malyar NM, Reinecke H, Lawall H. Impact of diabetes on outcome in critical limb ischemia with tissue loss: a large-scaled routine data analysis. Cardiovasc Diabetol 2017; 16:41. [PMID: 28376797 PMCID: PMC5379505 DOI: 10.1186/s12933-017-0524-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/25/2017] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Patients with diabetes concomitant to critical limb ischemia (CLI) represent a sub-group at particular risk. Objective of this analysis is to evaluate the actual impact of diabetes on treatment, outcome, and costs in a real-world scenario in Germany. METHODS We obtained routine-data on 15,332 patients with CLI with tissue loss from the largest German health insurance, BARMER GEK from 2009 to 2011, including a follow-up until 2013. Patient data were analyzed regarding co-diagnosis with diabetes with respect to risk profiles, treatment strategy, in-hospital and long-term outcome including costs. RESULTS Diabetic patients received less overall revascularizations in Rutherford grades 5 and 6 (Rutherford grade 5: 45.0 vs. 55.5%; Rutherford grade 6: 46.5 vs. 51.8; p < 0.001) and less vascular surgery (Rutherford grade 5: 13.4 vs. 23.4; Rutherford grade 6: 19.7 vs. 29.6; p < 0.001), however more often endovascular revascularization in Rutherford grade 6 (31.0 vs. 28.1; p = 0.004) compared to non-diabetic patients. Diabetes was associated with a higher observed ratio of infections (35.3 vs. 23.5% Rutherford grade 5; 44.3 vs. 27.4% Rutherford grade 6; p < 0.001) and in-hospital amputations (13.0 vs. 7.3% Rutherford grade 5; 47.5 vs. 36.7% Ruth6; p < 0.001). Diabetes further increased the risk for amputation during follow-up [Rutherford grade 5: HR 1.51 (1.38-1.67); Rutherford grade 6: HR 1.33 (1.25-1.41); p < 0.001], but not for death. CONCLUSIONS Diabetes increases markedly the risk of amputation attended by higher costs in CLI patients with tissue loss (OR 1.67 at Rutherford 5, OR 1.53 at Rutherford 6; p < 0.001), but is associated with lower revascularizations. However, in Rutherford grades 5 and 6, concomitant diabetes does not further worsen the overall poor survival.
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Affiliation(s)
- Eva Freisinger
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital Muenster, Albert Schweitzer Campus 1, A1, 48149, Muenster, Germany.
| | - Nasser M Malyar
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital Muenster, Albert Schweitzer Campus 1, A1, 48149, Muenster, Germany
| | - Holger Reinecke
- Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital Muenster, Albert Schweitzer Campus 1, A1, 48149, Muenster, Germany
| | - Holger Lawall
- Praxis für Herzkreislauferkrankungen und Akademie für Gefaeßkrankheiten, Ettlingen, Germany
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23
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Toe Pressure and Toe Brachial Index are Predictive of Cardiovascular Mortality, Overall Mortality, and Amputation Free Survival in Patients with Peripheral Artery Disease. Eur J Vasc Endovasc Surg 2017; 53:696-703. [PMID: 28292565 DOI: 10.1016/j.ejvs.2017.02.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 02/09/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE/BACKGROUND Peripheral haemodynamic parameters are used to assess the presence and severity of peripheral artery disease (PAD). The prognostic value of ankle brachial index (ABI) has been thoroughly delineated. Nonetheless, the relative usefulness of ankle pressure (AP), ABI, toe pressure (TP), and toe brachial index (TBI) in assessing patient outcome has not been investigated in a concurrent study setting. This study aimed to resolve the association of all four non-invasive haemodynamic parameters in clinically symptomatic patients with PAD with cardiovascular mortality, overall mortality, and amputation free survival (AFS). METHODS In total, 732 symptomatic patients with PAD admitted to the Department of Vascular Surgery for conventional angiography at Turku University Hospital, Turku, Finland, between January 2009 and August 2011 were reviewed retrospectively. Demographic factors, cardiovascular mortality, all-cause mortality, and above foot level amputations were obtained and assessed in relation to AP, ABI, TP, and TBI by means of Kaplan-Meier life tables and a multivariate Cox regression model. RESULTS The haemodynamic parameter that was associated with poor 36 month general outcome was TP < 30 mmHg. Univariate Cox regression analysis of stratified values showed that TP and TBI associated significantly with mortality. In multivariate analysis both TP and TBI were associated with a significant risk of death. For TP < 30 mmHg and TBI < 0.25 the risk of cardiovascular mortality was hazard ratio [HR] 2.84, 95% confidence interval [CI] 1.75-4.61 [p<.001]; HR 3.68, 95% CI 1.48-9.19 [p=.050], respectively; all-cause mortality (HR 2.05, 95% CI 1.44-2.92 [p<.001]; HR 2.53, 95% CI 1.35-4.74 [p=.040], respectively); and amputation or death (HR 2.13, 95% CI 1.52-2.98 [p<.001]; HR 2.46, 95% CI 1.38-4.40 [p=.050], respectively)... CONCLUSION Among non-invasive haemodynamic measurements and pressure indices both TP and TBI appear to be associated with cardiovascular and overall mortality and AFS for patients with PAD presenting symptoms of the disease.
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Zheng Y, Qin J, Wang X, Peng Z, Hou P, Lu X. Dynamic imaging of allogeneic adipose-derived regenerative cells transplanted in ischemic hind limb of apolipoprotein E mouse model. Int J Nanomedicine 2016; 12:61-71. [PMID: 28053524 PMCID: PMC5191626 DOI: 10.2147/ijn.s118328] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background Transplantation of allogeneic adipose-derived regenerative cells (ADRCs) is a promising treatment modality for severe ischemic diseases. However, minimal information is available on the in vivo effects, fate, and migration of ADRCs, as well as the mechanisms of their therapeutic angiogenesis. Materials and methods In this study, green fluorescent protein-expressing ADRCs (GFP-ADRCs) were obtained, labeled with acetylated 3-aminopropyltrimethoxysilane (APTS)-coated iron oxide nanoparticles (APTS NPs), and injected into an old apolipoprotein E knockout (ApoE-KO) mouse model with hind limb ischemia. Then, 3.0 T magnetic resonance imaging (MRI) was performed to dynamically trace the role of ADRCs targeting hind limb ischemia in the ApoE-KO mice model. Results Labeled cells were visualized as large hypointense spots in ischemic muscles by serial 3.0 T MRI scans during a 4-week follow-up. The presence of labeled GFP-ADRCs was confirmed by Prussian blue staining and fluorescence microscopy on postmortem specimens. Conclusion This study showed that allogeneic ADRCs offer great potential application for therapeutic angiogenesis in severe ischemic disease based on the efficacy and feasibility of ADRC transplantation and on the available amounts of tissue.
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Affiliation(s)
- Yi Zheng
- Department of General Surgery, The Fourth Affiliated Hospital of Guangxi Medical University, Guangxi
| | - Jinbao Qin
- Department of Vascular Surgery, School of Medicine, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University
| | - Xin Wang
- Department of Vascular Surgery, School of Medicine, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University
| | - Zhiyou Peng
- Department of Vascular Surgery, School of Medicine, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University
| | - Peiyong Hou
- Department of General Surgery, The Fourth Affiliated Hospital of Guangxi Medical University, Guangxi
| | - Xinwu Lu
- Department of Vascular Surgery, School of Medicine, Shanghai Ninth People's Hospital Affiliated to Shanghai JiaoTong University; Vascular Center of Shanghai JiaoTong University, Shanghai, People's Republic of China
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