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Müller AM, Räpple V, Bradaric C, Koppara T, Kehl V, Fusaro M, Cassese S, Ott I, Kastrati A, Laugwitz KL, Ibrahim T. Outcomes of endovascular treatment for infrapopliteal peripheral artery disease based on the updated TASC II classification. Vasc Med 2020; 26:18-25. [PMID: 33256573 DOI: 10.1177/1358863x20967091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We retrospectively analyzed all endovascular procedures of infrapopliteal arterial lesions (n = 383) performed in 270 patients at our institution between December 2008 and January 2018. The overall technical success rate was 97% and yielded 98% for stenoses (n = 214) and 95% for occlusions (n = 169). Trans-Atlantic Inter-Society Consensus (TASC II) classification had no impact on success rates (TASC A + B vs C + D; 96.5% vs 96.9%, p = 0.837). Freedom from clinically driven target lesion revascularization (TLR) after 6 and 12 months was 88.3% and 77.2%. TLR was comparable for TASC A to C lesions and no difference was observed comparing groups of moderately complex TASC A/B lesions and more complex TASC C/D lesions (TASC A + B vs C + D; 78.5% vs 74.2%, p = 0.457). Freedom from TLR was significantly lower in very complex TASC D lesions (TASC A + B + C vs D; 79.7% vs 42.5%, p < 0.001). Multivariate analysis identified TASC D lesions (hazard ratio D/A: 1.5; overall p = 0.002), Fontaine class III and IV (hazard ratio III or IV/IIa or IIb: 2.4; p = 0.041), and occlusive lesions (hazard ratio occlusion/stenosis: 2.4; p = 0.026) as predictors for TLR. In conclusion, endovascular therapy for infrapopliteal artery disease was safe and accompanied with a promising long-term outcome.
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Affiliation(s)
- Arne M Müller
- Klinikum rechts der Isar, Klinik und Poliklinik für Innere Medizin I., Technische Universität München, Munich, Germany
| | - Veronika Räpple
- Klinikum rechts der Isar, Klinik und Poliklinik für Innere Medizin I., Technische Universität München, Munich, Germany
| | - Christian Bradaric
- Klinikum rechts der Isar, Klinik und Poliklinik für Innere Medizin I., Technische Universität München, Munich, Germany
| | - Tobias Koppara
- Klinikum rechts der Isar, Klinik und Poliklinik für Innere Medizin I., Technische Universität München, Munich, Germany
| | - Victoria Kehl
- Klinikum rechts der Isar, Institut für Medizinische Informatik, Statistik und Epidemiologie, Technische Universität München, Munich, Germany
| | - Massimiliano Fusaro
- Deutsches Herzzentrum München, Abteilung für Herz- und Kreislauferkrankungen, Technische Universität München, Munich, Germany
| | - Salvatore Cassese
- Deutsches Herzzentrum München, Abteilung für Herz- und Kreislauferkrankungen, Technische Universität München, Munich, Germany
| | - Ilka Ott
- Helios Klinikum Pforzheim, Abteilung für Kardiologie, Angiologie und Intensivmedizin, Pforzheim, Germany
| | - Adnan Kastrati
- Deutsches Herzzentrum München, Abteilung für Herz- und Kreislauferkrankungen, Technische Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Karl-Ludwig Laugwitz
- Klinikum rechts der Isar, Klinik und Poliklinik für Innere Medizin I., Technische Universität München, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Tareq Ibrahim
- Klinikum rechts der Isar, Klinik und Poliklinik für Innere Medizin I., Technische Universität München, Munich, Germany
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2
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Miceli M, Baldi D, Cavaliere C, Soricelli A, Salvatore M, Napoli C. Peripheral artery disease: the new frontiers of imaging techniques to evaluate the evolution of regenerative medicine. Expert Rev Cardiovasc Ther 2019; 17:511-532. [PMID: 31220944 DOI: 10.1080/14779072.2019.1635012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Stem cells (ESC, iPSC, MSC) are known to have intrinsic regenerative properties. In the last decades numerous findings have favored the development of innovative therapeutic protocols based on the use of stem cells (Regenerative Medicine/Cell Therapy) for the treatment of numerous diseases including PAD, with promising results in preclinical studies. So far, several clinical studies have shown a general improvement of the patient's clinical outcome, however they possess many critical issues caused by the non-randomized design of the limited number of patients examined, the type cells to be used, their dosage, the short duration of treatment and also their delivery strategy. Areas covered: In this context, the use of the most advanced molecular imaging techniques will allow the visualization of very important physio-pathological processes otherwise invisible with conventional techniques, such as angiogenesis, also providing important structural and functional data. Expert opinion: The new frontier of cell therapy applied to PAD, potentially able to stop or even the process that causes the disease, with particular emphasis on the clinical aspects that different types of cells involve and on the use of more innovative molecular imaging techniques now available.
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Affiliation(s)
| | | | | | - Andrea Soricelli
- a IRCCS SDN , Naples , Italy.,b Department of Exercise and Wellness Sciences , University of Naples Parthenope , Naples , Italy
| | | | - Claudio Napoli
- a IRCCS SDN , Naples , Italy.,c University Department of Advanced Medical and Surgical Sciences, Clinical Department of Internal Medicine and Specialty Medicine , Università degli Studi della Campania 'Luigi Vanvitelli' , Napes , Italy
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3
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Outcomes of endovascular treatment versus bypass surgery for critical limb ischemia in patients with thromboangiitis obliterans. PLoS One 2018; 13:e0205305. [PMID: 30300407 PMCID: PMC6177182 DOI: 10.1371/journal.pone.0205305] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 09/21/2018] [Indexed: 11/23/2022] Open
Abstract
We aimed to compare the clinical outcomes between endovascular treatment and inframalleolar bypass surgery for critical limb ischemia (CLI) in patients with thromboangiitis obliterans (TAO) and to assess the role of bypass surgery in the era of innovative endovascular treatment. Between January 2007 and December 2017, a total of 33 consecutive patients with the diagnosis of TAO presenting with CLI who underwent endovascular treatment (endovascular group, n = 22) or bypass surgery to the pedal or plantar vessels (bypass group, n = 11) were included and analyzed retrospectively. The primary endpoint was defined as a major amputation of the index limb, and the secondary endpoint was defined as graft occlusion, regardless of the number of subsequent procedures. In the bypass group, six patients (55%) had undergone previous failed endovascular procedures and/or arterial bypass surgery to the index limb before inframalleolar bypass, and two patients (18%) received microvascular flap reconstruction after bypass surgery. During the median follow-up period of 32 months (range 1–115 months), there were no significant differences in primary and secondary endpoints between the two groups although the bypass group had a higher Rutherford class than the endovascular group. Kaplan–Meier survival analysis showed that there were similar limb salvage (P = 0.95) and graft patency rates (P = 0.39). In conclusion, endovascular treatment is a valid strategy leading to an acceptable limb salvage rate for TAO patients, and surgical bypass to distal target vessels could play a vital role in cases of previous failed endovascular treatment or extensive soft tissue loss of the foot.
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Ali SR, Ozdemir BA, Hinchliffe RJ. Critical Appraisal of the Quality of Evidence Addressing the Diagnosis, Prognosis, and Management of Peripheral Artery Disease in Patients With Diabetic Foot Ulceration. Eur J Vasc Endovasc Surg 2018; 56:401-408. [DOI: 10.1016/j.ejvs.2018.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 05/10/2018] [Indexed: 02/08/2023]
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5
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Molina Nácher V, Zaragozá García J, Morales Gisbert S, Ramírez Montoya M, Sala Almonacil V, Gómez Palonés F. Valor pronóstico de la clasificación WIfI en pacientes con pie diabético. ANGIOLOGIA 2017. [DOI: 10.1016/j.angio.2016.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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6
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Long-term Results of Inframalleolar Bypass for Critical Limb Ischaemia. Eur J Vasc Endovasc Surg 2016; 52:815-822. [DOI: 10.1016/j.ejvs.2016.08.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 08/29/2016] [Indexed: 11/21/2022]
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7
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Morisaki K, Yamaoka T, Iwasa K, Ohmine T. Popliteal-Peroneal Artery Bypass via the Posterior Approach: A Case Report. Ann Vasc Surg 2016; 36:292.e1-292.e4. [PMID: 27421203 DOI: 10.1016/j.avsg.2016.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 02/11/2016] [Accepted: 03/06/2016] [Indexed: 11/25/2022]
Abstract
We report the case of a 65-year-old man with critical limb ischemia treated with popliteal-peroneal bypass via the posterior approach and endarterectomy of the P2 popliteal artery. The posterior approach is useful in a number of situations, such as cases of arteriosclerotic disease of the crural arteries, where the target artery is the distal posterior tibial artery or peroneal artery; where the inflow site is the popliteal artery; in cases of a poor-quality greater saphenous vein, limited length of vein, and a preferable lesser saphenous vein; and in reoperation after failed bypass via a medial approach. Vascular surgeons should consider the posterior approach as an alternative procedure in below-knee revascularization.
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Affiliation(s)
- Koichi Morisaki
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Ehime, Japan.
| | - Terutoshi Yamaoka
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Ehime, Japan
| | - Kazuomi Iwasa
- Department of Vascular Surgery, Matsuyama Red Cross Hospital, Matsuyama, Ehime, Japan
| | - Takahiro Ohmine
- Department of Vascular Surgery, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Hiroshima, Japan
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8
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Eskelinen E, Lepäntalo M. Role of Infrainguinal Angioplasty in the Treatment of Critical Limb Ischaemia. Scand J Surg 2016; 96:11-6. [PMID: 17461306 DOI: 10.1177/145749690709600103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Objective: To review the published papers reporting on the use of infrainguinal angioplasty in the treatment of critical limb ischaemia (CLI). Methods: A MEDLINE (1966–2005) and Cochrane library search for articles relating to the use of infrainguinal angioplasty in the treatment of CLI. Results: Recent papers reporting on the results of infrainguinal angioplasty as treatment for CLI patients show excellent limb salvage rates regardless of the patency rates. The Cochrane Database of systematic reviews has accepted two prospective randomised trials comparing bypass operations and angioplasty among CLI patients. Pooling both trials showed no overall significant difference in amputation rates between the surgery and PTA groups. A multicentre, randomised controlled trial, the BASIL (bypass versus Angioplasty in Severe Ischaemia of the Leg) trial showed that in the medium term (after six months), the outcomes after angioplasty or surgery among CLI patients did not differ significantly with respect to amputation-free survival, all-cause mortality and quality of life. Conclusions: Infrainguinal PTA is feasible in CLI patients. Data from the BASIL trial show the similar ability of bypass surgery and balloon angioplasty in preserving both life and limb in short term. These results are, however, not applicable for the majority of CLI patients as only 15% (70/456) of the patients with severe limb ischaemia were considered candidates for the trial.
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Affiliation(s)
- E Eskelinen
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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9
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Hinchliffe RJ, Brownrigg JRW, Andros G, Apelqvist J, Boyko EJ, Fitridge R, Mills JL, Reekers J, Shearman CP, Zierler RE, Schaper NC. Effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral artery disease: a systematic review. Diabetes Metab Res Rev 2016; 32 Suppl 1:136-44. [PMID: 26342204 DOI: 10.1002/dmrr.2705] [Citation(s) in RCA: 94] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Symptoms or signs of peripheral artery disease (PAD) can be observed in up to 50% of the patients with a diabetic foot ulcer and is a risk factor for poor healing and amputation. In 2012, a multidisciplinary working group of the International Working Group on the Diabetic Foot published a systematic review on the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. This publication is an update of this review and now includes the results of a systematic search for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980 to June 2014. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 56 articles were eligible for full-text review. There were no randomized controlled trials, but there were four nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70-89%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular techniques. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of conservatively treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients.
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Affiliation(s)
- R J Hinchliffe
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK
| | - J R W Brownrigg
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK
| | - G Andros
- Amputation Prevention Center, Valley Presbyterian Hospital, Los Angeles, CA, USA
| | - J Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - E J Boyko
- Seattle Epidemiologic Research and Information Centre, Department of Veterans Affairs Puget Sound Health Care System, University of Washington, Seattle, WA, USA
| | - R Fitridge
- Vascular Surgery, The University of Adelaide, Adelaide, South Australia, Australia
| | - J L Mills
- Michael E. Debakey Department of Surgery, Baylor College of Medicine, Houston, USA
| | - J Reekers
- Department of Vascular Radiology, Amsterdam Medical Centre, Amsterdam, The Netherlands
| | - C P Shearman
- Department of Vascular Surgery, Southampton University Hospitals NHS Trust, Southampton, UK
| | - R E Zierler
- Department of Surgery, University of Washington, Seattle, WA, USA
| | - N C Schaper
- Division Endocrinology, MUMC+, CARIM Institute, Maastricht, The Netherlands
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10
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Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, Reekers J, Norgren L. An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries: A Supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II): The TASC Steering Comittee(.). Ann Vasc Dis 2015; 8:343-57. [PMID: 26730266 DOI: 10.3400/avd.tasc.15-01000] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.
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Affiliation(s)
| | - Christopher J White
- The Ochsner Clinical School-University of Queensland, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - William R Hiatt
- Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora, CO, USA
| | - Gerry R Fowkes
- Centre for Population Health Sciences, The University of Edinburgh, UK
| | | | | | - Jim Reekers
- Academic Medical Center, University Hospital, Amsterdam, The Netherlands
| | - Lars Norgren
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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11
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Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, Reekers J, Norgren L. An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries: A Supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Vasc Med 2015; 20:465-78. [DOI: 10.1177/1358863x15597877] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.
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Affiliation(s)
| | | | - Christopher J. White
- The Ochsner Clinical School–University of Queensland, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - William R. Hiatt
- Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora, CO, USA
| | - Gerry R. Fowkes
- Centre for Population Health Sciences, The University of Edinburgh, UK
| | | | | | - Jim Reekers
- Academic Medical Center, University Hospital, Amsterdam, The Netherlands
| | - Lars Norgren
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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12
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Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, Reekers J, Norgren L. An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: A supplement to the inter-society consensus for the management of peripheral arterial disease (TASC II): The TASC steering commi. Catheter Cardiovasc Interv 2015; 86:611-25. [DOI: 10.1002/ccd.26122] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | - Christopher J. White
- The Ochsner Clinical School-University of Queensland, Ochsner Clinic Foundation; New Orleans LA USA
| | - William R. Hiatt
- Division of Cardiology; University of Colorado School of Medicine, and CPC Clinical Research; Aurora CO USA
| | - Gerry R. Fowkes
- Centre for Population Health Sciences, The University of Edinburgh; UK
| | | | | | - Jim Reekers
- Academic Medical Center, University Hospital; Amsterdam The Netherlands
| | - Lars Norgren
- Department of Surgery; Faculty of Medicine and Health, Örebro University; Örebro Sweden
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13
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Jaff MR, White CJ, Hiatt WR, Fowkes GR, Dormandy J, Razavi M, Reekers J, Norgren L. An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries. J Endovasc Ther 2015; 22:663-77. [DOI: 10.1177/1526602815592206] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) guidelines were last updated in 2007 (TASC II) and represented the collaboration of international vascular specialties involved in the management of patients with peripheral arterial disease (PAD). Since the publication of TASC II, there have been innovations in endovascular revascularization strategies for patients with PAD. The intent of this publication is to provide a complete anatomic lower limb TASC lesion classification, including the infrapopliteal segment, and an updated literature review of new endovascular techniques and practice patterns employed by vascular specialists today.
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Affiliation(s)
| | | | - Christopher J. White
- The Ochsner Clinical School–University of Queensland, Ochsner Clinic Foundation, New Orleans, LA, USA
| | - William R. Hiatt
- Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora, CO, USA
| | - Gerry R. Fowkes
- Centre for Population Health Sciences, The University of Edinburgh, UK
| | | | | | - Jim Reekers
- Academic Medical Center, University Hospital, Amsterdam, The Netherlands
| | - Lars Norgren
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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14
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Miyahara T, Shigematsu K, Nishiyama A, Hashimoto T, Hoshina K, Watanabe T. Long-term results of combined aortoiliac and infrainguinal arterial reconstruction for the treatment of critical limb ischemia. Ann Vasc Dis 2015; 8:14-20. [PMID: 25848426 DOI: 10.3400/avd.oa.14-00119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/07/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE This study was designed to investigate our long-term experience with combined iliac endovascular therapy (EVT) and infrainguinal bypass to treat critical limb ischemia (CLI) and compare outcomes to those of patients who underwent surgery for aortoiliac lesions. MATERIALS AND METHODS From April 2000 to June 2013, 57 patients (58 limbs) underwent an infrainguinal bypass combined with aortoiliac reconstruction to treat CLI. Eighteen limbs were treated by bypass alone and 8 limbs were treated by bypass with EVT for aortoiliac lesions (Bypass group). Thirty-two limbs were subjected to EVT alone for iliac lesions (EVT group). RESULTS Preoperative limb ischemia was more severe in the EVT group. There were no significant differences in major procedure-related complications (χ(2) test, P = 0.853), systemic complications (P = 0.853), and mortality (P = 0.916) between the 2 groups. The limb salvage rates were 92% at 1, 3, and 5 years in the Bypass group and 93% at 1, 3, and 5 years in the EVT group, with no significant difference observed between the groups (Kaplan-Meier, log-rank test, P = 0.616). CONCLUSION Infrainguinal surgical reconstruction combined with an iliac EVT is an acceptable strategy for managing patients with CLI.
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Affiliation(s)
- Takuya Miyahara
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan
| | - Kunihiro Shigematsu
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan
| | - Ayako Nishiyama
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan
| | - Takuya Hashimoto
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan
| | - Katsuyuki Hoshina
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan
| | - Toshiaki Watanabe
- Division of Vascular Surgery, Department of Surgery, The University of Tokyo, Tokyo, Japan
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15
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Moreira RWDC, Costa PVAD, Carrilho DDR. Treatment of critical lower limb ischemia using a hybrid technique. J Vasc Bras 2014. [DOI: 10.1590/jvb.2014.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Critical ischemia of a lower limb is a condition that threatens its viability and must be treated promptly to avoid major amputation. Revascularization is the most effective treatment method and is performed using surgical or endovascular techniques. For patients with thoracoabdominal aortic aneurysms, combining these two approaches into a "hybrid technique" makes it possible to treat patients who could not be adequately treated by either technique in isolation. We report on a case of lower limb critical ischemia treated using a combination of surgery and endovascular techniques, in an application of the hybrid technique in a different arterial bed.
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16
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Comprehensive Approach to Management of Critical Limb Ischemia. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:332. [DOI: 10.1007/s11936-014-0332-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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Ballotta E, Toniato A, Piatto G, Mazzalai F, Da Giau G. Lower extremity arterial reconstruction for critical limb ischemia in diabetes. J Vasc Surg 2014; 59:708-19. [DOI: 10.1016/j.jvs.2013.08.103] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 08/19/2013] [Accepted: 08/22/2013] [Indexed: 10/25/2022]
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Dorweiler B, Friess T, Duenschede F, Doemland M, Espinola-Klein C, Vahl CF. Value of the deep femoral artery as alternative inflow source in infrainguinal bypass surgery. Ann Vasc Surg 2013; 28:633-9. [PMID: 24360628 DOI: 10.1016/j.avsg.2013.04.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 04/23/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to analyze the long-term results of infrainguinal bypass surgery using the deep femoral artery (DFA) as the inflow source. METHODS Between 1998 and 2011, 88 bypasses of the lower limb were placed in 86 patients (mean age 71 years) using the deep femoral artery as inflow. Patients' records were retrieved from a computerized database and analyzed retrospectively. RESULTS Critical limb ischemia (rest pain/tissue loss) was the indication in the majority (87.5%) of cases. The distal anastomosis of the bypass grafts was located at the popliteal level in 32 cases and the tibial (pedal) level in 52 cases, respectively, with the autologous vein as conduit in 94% of cases. Perioperative mortality was 2.3% and 77 patients (79 limbs) were followed over a mean period of 48 months. Overall primary, primary assisted, and secondary patency rates of 64.2%, 74.9%, and 92.3% were noted at 60 months, respectively. The limb salvage rate was 97%, with an overall survival of 48.7% at 60 months. CONCLUSIONS The deep femoral artery can serve as reliable inflow source for infrainguinal bypass surgery in difficult situations like redo groin surgery, limited conduit length, and circumferential nonobstructive calcification of the common femoral artery.
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Affiliation(s)
- Bernhard Dorweiler
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Johannes-Gutenberg University, Mainz, Germany.
| | - Tanja Friess
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Johannes-Gutenberg University, Mainz, Germany
| | - Friedrich Duenschede
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Johannes-Gutenberg University, Mainz, Germany
| | - Marco Doemland
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Johannes-Gutenberg University, Mainz, Germany
| | - Christine Espinola-Klein
- Division of Angiology, II Medical Clinic, University Medical Center, Johannes-Gutenberg University, Mainz, Germany
| | - Christian-Friedrich Vahl
- Division of Vascular Surgery, Department of Cardiothoracic and Vascular Surgery, Johannes-Gutenberg University, Mainz, Germany
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19
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Bunte MC, Shishehbor MH. Treatment of infrapopliteal critical limb ischemia in 2013: the wound perfusion approach. Curr Cardiol Rep 2013; 15:363. [PMID: 23605465 DOI: 10.1007/s11886-013-0363-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The primary goals of treatment for critical limb ischemia (CLI) are alleviation of ischemic rest pain, healing of arterial insufficiency ulcers, and improving quality of life. These goals are directed toward preventing limb loss and CLI-related mortality. Arterial revascularization serves as the foundation of a contemporary approach to promote amputation-free survival. Mounting evidence supports a wound-directed angiosome revascularization approach, increasingly achieved with endovascular techniques. Innovations in technology and wound-perfusion strategy have advanced patient care and are accelerating the pace of CLI treatment. The evolving angiosome revascularization approach has been augmented with a multidisciplinary wound care strategy that deserves particular emphasis. These state-of-the-art advances in CLI management are reported herein with considerations for the future treatment of CLI.
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Affiliation(s)
- Matthew C Bunte
- Robert & Suzanne Tomsich Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Mail code J3-5, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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20
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Lepäntalo M, Apelqvist J, Setacci C, Ricco JB, de Donato G, Becker F, Robert-Ebadi H, Cao P, Eckstein HH, De Rango P, Diehm N, Schmidli J, Teraa M, Moll FL, Dick F, Davies AH. Chapter V: Diabetic foot. Eur J Vasc Endovasc Surg 2012; 42 Suppl 2:S60-74. [PMID: 22172474 DOI: 10.1016/s1078-5884(11)60012-9] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Ulcerated diabetic foot is a complex problem. Ischaemia, neuropathy and infection are the three pathological components that lead to diabetic foot complications, and they frequently occur together as an aetiologic triad. Neuropathy and ischaemia are the initiating factors, most often together as neuroischaemia, whereas infection is mostly a consequence. The role of peripheral arterial disease in diabetic foot has long been underestimated as typical ischaemic symptoms are less frequent in diabetics with ischaemia than in non-diabetics. Furthermore, the healing of a neuroischaemic ulcer is hampered by microvascular dysfunction. Therefore, the threshold for revascularising neuroischaemic ulcers should be lower than that for purely ischaemic ulcers. Previous guidelines have largely ignored these specific demands related to ulcerated neuroischaemic diabetic feet. Any diabetic foot ulcer should always be considered to have vascular impairment unless otherwise proven. Early referral, non-invasive vascular testing, imaging and intervention are crucial to improve diabetic foot ulcer healing and to prevent amputation. Timing is essential, as the window of opportunity to heal the ulcer and save the leg is easily missed. This chapter underlines the paucity of data on the best way to diagnose and treat these diabetic patients. Most of the studies dealing with neuroischaemic diabetic feet are not comparable in terms of patient populations, interventions or outcome. Therefore, there is an urgent need for a paradigm shift in diabetic foot care; that is, a new approach and classification of diabetics with vascular impairment in regard to clinical practice and research. A multidisciplinary approach needs to implemented systematically with a vascular surgeon as an integrated member. New strategies must be developed and implemented for diabetic foot patients with vascular impairment, to improve healing, to speed up healing rate and to avoid amputation, irrespective of the intervention technology chosen. Focused studies on the value of predictive tests, new treatment modalities as well as selective and targeted strategies are needed. As specific data on ulcerated neuroischaemic diabetic feet are scarce, recommendations are often of low grade.
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Affiliation(s)
- M Lepäntalo
- Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland.
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21
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Abstract
The role of peripheral arterial disease in ulcerated diabetic feet has long been underestimated. Progressive claudication, rest pain and the extent of irreversible tissue loss have frequently been indications for revascularization for neuroischaemic ulcers in diabetic patients. These typical ischaemic symptoms are warning signs that are less frequent in diabetic individuals with ischaemia than those without diabetes. Consequently, 30-50% of individuals with diabetes and foot ulcers already have gangrene at admission and are therefore often considered unsuitable for revascularization. Furthermore, the healing of a neuroischaemic ulcer is worsened by microvascular dysfunction, causing arteriovenous shunting, capillary ischaemia, leakage and venous pooling. Therefore, the threshold of revascularizing neuroischaemic ulcers should be lower than that of purely ischaemic ulcers. Comorbidity, ulcer characteristics and infection affect the decision as to when to intervene, as do the severity and extent of occlusive arterial lesions. The window of opportunity for vascular intervention in the neuroischaemic diabetic foot should not be missed, and the need for early vascular intervention as an integrated part of a strategy to achieve healing should be emphasized. Noninvasive vascular testing should be performed on all individuals with an ulcerated diabetic foot. The arterial tree should be imaged if noninvasive tests indicate ischaemia or when mild or questionable ischaemia is diagnosed and conservative treatment does not promote ulcer healing in 6 weeks. Revascularization should be performed whenever feasible to repair distal perfusion to achieve ulcer healing.
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Affiliation(s)
- J A P Apelqvist
- Department of Endocrinology, Malmö University Hospital, Malmö, Sweden.
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22
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Hinchliffe RJ, Andros G, Apelqvist J, Bakker K, Friederichs S, Lammer J, Lepantalo M, Mills JL, Reekers J, Shearman CP, Valk G, Zierler RE, Schaper NC. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res Rev 2012; 28 Suppl 1:179-217. [PMID: 22271740 DOI: 10.1002/dmrr.2249] [Citation(s) in RCA: 145] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In several large recent observational studies, peripheral arterial disease (PAD) was present in up to 50% of the patients with a diabetic foot ulcer and was an independent risk factor for amputation. The International Working Group on the Diabetic Foot therefore established a multidisciplinary working group to evaluate the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. A systematic search was performed for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980-June 2010. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 49 papers were eligible for full text review. There were no randomized controlled trials, but there were three nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70.5-85.5%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular revascularization. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of medically treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients.
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Affiliation(s)
- R J Hinchliffe
- St George's Vascular Institute, St George's Healthcare NHS Trust, London, UK.
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23
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Engelhardt M, Boos J, Bruijnen H, Wohlgemuth W, Willy C, Tannheimer M, Wölfle K. Critical Limb Ischaemia: Initial Treatment and Predictors of Amputation-free Survival. Eur J Vasc Endovasc Surg 2012; 43:55-61. [DOI: 10.1016/j.ejvs.2011.09.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 09/09/2011] [Indexed: 10/16/2022]
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25
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Lumsden AB, Davies MG, Peden EK. Medical and endovascular management of critical limb ischemia. J Endovasc Ther 2009; 16:II31-62. [PMID: 19624074 DOI: 10.1583/08-2657.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Critical limb ischemia (CLI) is the term used to designate the condition in which peripheral artery disease has resulted in resting leg or foot pain or in a breakdown of the skin of the leg or foot, causing ulcers or tissue loss. If not revascularized, CLI patients are at risk for limb loss and for potentially fatal complications from the progression of gangrene and the development of sepsis. The management of CLI requires a multidisciplinary team of experts in different areas of vascular disease, from atherosclerotic risk factor management to imaging, from intervention to wound care and physical therapy. In the past decade, the most significant change in the treatment of CLI has been the increasing tendency to shift from bypass surgery to less invasive endovascular procedures as first-choice revascularization techniques, with bypass surgery then reserved as backup if appropriate. The goals of intervention for CLI include the restoration of pulsatile, inline flow to the foot to assist wound healing, the relief of rest pain, the avoidance of major amputation, preservation of mobility, and improvement of patient function and quality of life. The evaluating physician should be fully aware of all revascularization options in order to select the most appropriate intervention or combination of interventions, while taking into consideration the goals of therapy, risk-benefit ratios, patient comorbidities, and life expectancy. We discuss the incidence, risk factors, and prognosis of CLI and the clinical presentation, diagnosis, available imaging modalities, and medical management (including pain and ulcer care, pharmaceutical options, and molecular therapies targeting angiogenesis). The endovascular approaches that we review include percutaneous transluminal angioplasty (with or without adjunctive stenting); subintimal angioplasty; primary femoropopliteal and infrapopliteal deployment of bare nitinol, covered, drug-eluting, or bioabsorbable stents; cryoplasty; excimer laser-assisted angioplasty; excisional atherectomy; and cutting balloon angioplasty.
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Affiliation(s)
- Alan B Lumsden
- Department of Cardiovascular Surgery, Methodist DeBakey Heart and Vascular Center, The Methodist Hospital, 6550 Fannin Street, Suite 1401, Houston, TX 77030, USA.
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26
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Paraskevas KI, Baker DM, Pompella A, Mikhailidis DP. Does Diabetes Mellitus Play a Role in Restenosis and Patency Rates Following Lower Extremity Peripheral Arterial Revascularization? A Critical Overview. Ann Vasc Surg 2008; 22:481-91. [DOI: 10.1016/j.avsg.2007.12.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Accepted: 12/26/2007] [Indexed: 10/21/2022]
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Domenig CM, Aspalter M, Umathum M, Holzenbein TJ. Redo Pedal Bypass Surgery after Pedal Graft Failure: Gain or Gadget? Ann Vasc Surg 2007; 21:713-8. [DOI: 10.1016/j.avsg.2007.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2007] [Revised: 06/15/2007] [Accepted: 07/15/2007] [Indexed: 11/16/2022]
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28
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Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FGR. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S:S5-67. [PMID: 17223489 DOI: 10.1016/j.jvs.2006.12.037] [Citation(s) in RCA: 3853] [Impact Index Per Article: 226.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- L Norgren
- Department of Surgery, University Hospital, Orebro, Sweden
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29
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Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FGR, Bell K, Caporusso J, Durand-Zaleski I, Komori K, Lammer J, Liapis C, Novo S, Razavi M, Robbs J, Schaper N, Shigematsu H, Sapoval M, White C, White J, Clement D, Creager M, Jaff M, Mohler E, Rutherford RB, Sheehan P, Sillesen H, Rosenfield K. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Endovasc Surg 2006; 33 Suppl 1:S1-75. [PMID: 17140820 DOI: 10.1016/j.ejvs.2006.09.024] [Citation(s) in RCA: 1795] [Impact Index Per Article: 99.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Accepted: 09/15/2006] [Indexed: 01/19/2023]
Affiliation(s)
- L Norgren
- Department of Surgery, University Hospital, Orebro, Sweden.
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Awad S, Karkos CD, Serrachino-Inglott F, Cooper NJ, Butterfield JS, Ashleigh R, Nasim A. The impact of diabetes on current revascularisation practice and clinical outcome in patients with critical lower limb ischaemia. Eur J Vasc Endovasc Surg 2006; 32:51-9. [PMID: 16488631 DOI: 10.1016/j.ejvs.2005.12.019] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Accepted: 12/23/2005] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To compare current revascularisation practice and outcome in diabetic and non-diabetic patients presenting with critical limb ischaemia (CLI) to a single vascular surgeon. METHODS Data for 113 patients presenting with CLI were collected prospectively over a 3-year period. Forty-four (39%) were diabetic. Treatment was classified as percutaneous angioplasty, arterial reconstruction, primary major amputation, and conservative therapy. Main outcome measures were 30-day mortality, major amputation, survival, and amputation-free survival. RESULTS Diabetic patients were more likely to present with gangrene, give a history of angina, be treated with nitrates and statins, and have lower cholesterol levels. No significant differences were found in the initial treatment options between diabetics and non-diabetics: angioplasty 39 vs 26%, surgical revascularisation 34 vs 33%, primary major amputation 9% vs 17%, and conservative treatment 11 vs 19% (p = ns in all). There were eight deaths (7%) within 30-days. At follow-up (1-44 months, median 14 months), rates of major amputation and death for the entire population were 23 and 8%, respectively. The 12-month cumulative survival and amputation-free survival rates were 90 and 72%, respectively. When comparing diabetic to non-diabetic patients, there were no significant differences in the 30-day mortality (6.8 vs 7.2%, p = 0.4), cumulative survival (93 vs 89% at 12 months, log-rank test: 0.00, p = 0.9), amputation-free survival (71 vs 73% at 12 months, log-rank test: 0.00, p = 0.99), and major amputation rates (22.7 vs 23.1% at 12 months, p = 0.96). Similarly, there were no differences in limb salvage rates between diabetic and non-diabetic patients undergoing revascularisation procedures (78 vs 90% at 12 months, log-rank test: 2.04, p = 0.15). CONCLUSIONS In current practice, an aggressive multidisciplinary approach in diabetic patients presenting with CLI leads to similar limb salvage, amputation-free survival, mortality, and major amputation rates to those seen in non-diabetic patients. The presence of diabetes should not deter clinicians from attempting revascularisation by means of angioplasty or surgical reconstruction.
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Affiliation(s)
- S Awad
- Department of Vascular and Endovascular Surgery, Leicester Royal Infirmary, University of Leicester, Leicester, UK
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31
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Domenig CM, Hamdan AD, Holzenbein TJ, Kansal N, Aulivola B, Skillman JJ, Campbell DR, LoGerfo FW, Pomposelli FB. Timing of Pedal Bypass Failure and Its Impact on the Need for Amputation. Ann Vasc Surg 2005; 19:56-62. [PMID: 15714368 DOI: 10.1007/s10016-004-0137-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Although the utility of dorsalis pedis (DP) bypass for limb ischemia has been well established, the fate of limbs with a failed bypass to the DP artery remains unclear. Data of all patients undergoing DP bypass grafting within a 12-year period from two university hospitals' vascular registries were retrospectively reviewed. Outcomes of early (<30 days) and delayed graft failure (>30 days) were examined. The Student's t-test and chi-squared test were used for univariate analysis; patency rates and patient survival were calculated using the Kaplan-Meier product limit method. Of 1434 DP bypass grafts, 277 (19.3%) failed grafts were identified. Sixty five (4.5%) grafts failed early (within 30 days of surgery) and 212 (14.8%) failed late at a mean time of 15.3 months (range, 1.5-105 months) after initial bypass. Of the 65 limbs with early graft failure, 28 (43.1%) proceeded directly to amputation and 20 underwent additional revascularization attempts, but limb salvage was achieved in only 7 patients; in 45 (69.2%) patients no further revascularizations were attempted. Seventy-four (34.9%) patients with late graft failure underwent redo revascularization. Thirty-nine (52.6%) had their limb saved with graft revision, but 35 patients (47.3%) ultimately lost their limb. In 138 patients with late graft failure (65.1%) no further revascularization attempts were performed. Sixty-two (44.9%) required major amputation. Overall, 49.8% of patients with failed pedal grafts ultimately suffered limb loss. Early graft failure resulted in a significantly higher rate of major amputation that did late graft failure (63.1% vs. 45.8%, respectively; p = 0.015). These results indicate that early occlusion of pedal bypass often leads to immediate major amputation and interventions to maintain graft patency in this setting are often futile. Late failure of pedal bypass is associated with a lower likelihood of amputation because of a higher rate of success of bypass revisions and a lower occurrence of critical ischemia with graft failure.
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Affiliation(s)
- Christoph M Domenig
- Division of Vascular Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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By-pass distales a arterias perimaleolares en la isquemia crítica de las extremidades inferiores. ANGIOLOGIA 2004. [DOI: 10.1016/s0003-3170(04)74887-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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