The effect of iloprost in patients with rest pain

Transcutaneous Oxygen and Carbon Dioxide Levels with Iloprost Administration in Diabetic Critical Limb Ischemia

Iloprost, a prostacyclin analogue, is a treatment option for surgically unsuitable diabetic chronic critical limb ischemia (CLI), although its outcome is difficult to be anticipated clinically. Whether transcutaneous (tc) oxygen tension (PO2) predicts the response to iloprost in diabetic CLI is unclear at this point and, in that same context, the prognostic role of tc carbon dioxide tension (PCO2), another ischemia-sensitive parameter, is unknown. Supine and dependent tcPO2 and tcPCO2 were measured at baseline and after 4 weeks of iloprost treatment in 31 limbs of 26 type-2 diabetic arteriopaths with CLI not amenable to surgery. Success was defined as pain relief and significant reduction of analgesics. Clinical outcome was stratified by baseline tcPO2 and tcPCO2 tertiles, and likelihood ratios (LR) quantified the increase from pretest chances given a certain result. Iloprost succeeded in 16 (52%) and failed in 15 limbs (48%) and post-treatment tcPO2 followed a parallel course. Failures increased by ascending baseline tcPCO2 and descending tcPO2 tertiles; successes behaved specularly. Predictions of failure based on elevated tcPCO2 (>53 mm Hg) were more efficient than relying on depressed tcPO2 (LR 10.7 vs 3.6); success was almost certain when tcPO2 was >23 mm Hg (LR = 17.8). Dependent determinations were less useful than supine measurements for prognostic use. Elevated tcPCO2 predicted failure efficiently and high tcPO2 was a useful prognostic tool for success of iloprost, suggesting that their combined use may allow better prognostic stratification and improve the therapeutic approach to diabetic CLI.

Efficacy of a novel method of intravenous infusion of the prostaglandin analogue iloprost for the treatment of lower-limb critical ischemia: An open-label, nonrandomized study in two cohorts

BACKGROUND

Patients with advanced peripheral atherosclerotic occlusive disease who are no longer candidates for either surgical or intravascular treatment or who have undergone unsuccessful surgical revascularization may be treated with IV prostanoids.

OBJECTIVE

The aim of this study was to assess the efficacy, tolerability, compliance, and cost of a new system of prostanoid administration that provides a constant plasma concentration of iloprost and maintains the efficacy of the drug while reducing the risk for adverse effects (AEs) and the overall cost of treatment compared with the actually adopted infusion system.

METHODS

This open-label, nonrandomized study was conducted at the University Hospital of Catania (Catania, Italy). Patients with chronic critical ischemia who were not candidates for surgical revascularization were observed. The study population was divided into 2 groups: patients in group A were treated with a continuous 6-hour IV infusion of iloprost 0.5 to 2.0 ng/kg.min once daily for at least 14 consecutive days, and patients in group B were treated with a 20-day iloprost continuous IV infusion at a mean dosage of 25 μg/d by means of a portable elastomeric infusion system. Every 5 days the patient was admitted to the day-hospital setting to replenish the drug. Primary end points were rates of major and minor amputations and death; secondary end points were complete relief or a marked reduction of pain at rest, as reflected by discontinuation of analgesic therapy and by a decrease in the patients' complaints of pain, as well as by the satisfactory healing of ulcerations. Tolerability, compliance, and cost also were assessed.

RESULTS

Fifty-six patients (34 men, 22 women; mean [SD] age, 67 [11] years) entered the study. Group A comprised 25 patients; group B, 31 patients. The rate of major amputation in patients at Fontaine stage IV was higher in group A (33.3%) compared with group B (20.0%). The death rate was higher in group A (4.0%) than in group B (3.2%). Pain at rest completely subsided in 37.5% of patients in group A and 68.8% of patients in group B. Trophic lesions healed in 44.4% and 73.3% of patients in groups A and B, respectively. In group A, 40.0% of patients experienced AEs (ie, hyperemia, headache, flushing) that required a reduction in dose. In group B, 6.5% of patients had hyperemia at the injection site that required a reduction in dose. Total cost wasin group B wasd €1995.60, with a mean hospital stay of 6 days. Overall, patients' quality of life, assessed as the ability to resume their normal social activities, improved.

CONCLUSIONS

In this study of patients with chronic lower-limb critical ischemia, due to the consistent blood level achieved with iloprost, 20-day iloprost continuous IV infusion at a mean dosage of 25 μg/d administered by means of a portable elastomeric infusion system was shown to be similarly or more effective than the Methods used by the most important European trials (ie, iloprost 0.5-2.0 ng/kg·min once daily for at least 14 consecutive days). Furthermore, the patients were more compliant and the cost of treatment and the length of hospitalization were reduced compared with iloprost 0.5 to 2.0 ng/kg·min once daily for at least 14 consecutive days.

Improvement of the Walking Ability in Intermittent Claudication due to Superficial Femoral Artery Occlusion with Supervised Exercise and Pneumatic Foot and Calf Compression: A Randomised Controlled Trial

OBJECTIVES

To compare the effect of unsupervised exercise, supervised exercise and intermittent pneumatic foot and calf compression (IPC) on the claudication distance, lower limb arterial haemodynamics and quality of life of patients with intermittent claudication.

METHODS

Thirty-four eligible patients with stable intermittent claudication were randomised to IPC (n = 13, 3h/d for 6 months), supervised exercise (n = 12, three hourly sessions/week for 6 months) or unsupervised exercise (n = 9). In each patient, initial claudication distance (ICD), absolute claudication distance (ACD), resting ankle brachial pressure index (ABPI), and resting hyperaemic calf arterial inflow were measured before, 6 weeks, 6 months and 1 year after randomisation. Quality of life was assessed with the short form (SF)-36, walking impairment (WIQ) and intermittent claudication questionnaires (ICQ).

RESULTS

Compared with unsupervised exercise, both IPC and supervised exercise, increased ICD and ACD, up to 2.83 times. IPC increased arterial inflow (p < 0.05 at 6 weeks) and ABPI. Supervised exercise decreased arterial inflow and increased ABPI (p < 0.05 at 6 months). Unsupervised exercise had no effect on arterial inflow or ABPI. IPC improved significantly the ICQ score and the speed score of the WIQ, while supervised exercise improved the WIQ claudication severity score. At 1 year clinical effectiveness of supervised exercise and IPC was largely preserved.

CONCLUSIONS

IPC, by augmenting leg perfusion, achieved improvement in walking distance comparable with supervised exercise. Long-term results in a larger number of patients will provide valuable information on the optimal treatment modality of intermittent claudication.

Functional outcome after infrainguinal bypass for limb salvage

PURPOSE

Functional outcome after infrainguinal bypass (IB) has recently been assessed with global health status questionnaires but not by criteria specific to the objectives of IB (i.e., maintenance of independent living and ambulation). Preoperative and postoperative living situation and ambulatory status were evaluated in patients who underwent IB for limb salvage (LS) indications.

METHODS

For patients in whom IB was performed for LS from January 1980 to July 1995, living situation (independent or dependent) and ambulatory status were assessed before the onset of the need for LS surgery and 6 months after surgery. The importance of risk factors (age, sex, diabetes, heart disease, hypertension, renal insufficiency or failure, previous leg bypass, indication for surgery, postoperative morbidity, graft patency) was assessed by multivariate analysis.

RESULTS

IB for LS was performed in 513 patients. Before the development of the indication for LS surgery, 92% lived independently and 91% were ambulatory. The operative mortality rate was 2.7%. At 6 months, 86% were alive and the assisted primary graft patency rate was 92%. Ninety-nine percent of survivors who lived independently before developing the need for LS surgery remained independent 6 months after surgery, and 97% of those who were ambulatory before developing the need for LS surgery were ambulatory 6 months after surgery. Only one of 25 survivors (4%) who were not living independently before surgery achieved independent living 6 months after surgery. Twenty-one percent of nonambulatory patients (6 of 29) became ambulatory. Multivariate analysis confirmed the importance of preoperative living situation and ambulatory status in predicting outcome at 6 months (p < 0.0001). Amputation and loss of primary patency were predictive of poor ambulatory status at 6 months (p < 0.0001, p = 0.025, respectively). The overall 5-year survival rate was 48.1%.

CONCLUSIONS

Preoperative independence and ambulation best predict postoperative independence and ambulation after IB for LS indications. IB procedures performed for limb salvage have a low operative mortality rate and maintain independent living and ambulation in 99% and 97% of patients, respectively. Poor overall long-term outcome and survival in LS patients results from intercurrent illness and not from IB.