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Choinski KN, Rao AG, Krishnan P, Tadros RO, Sharma R, Faries PL. Single Center Outcomes of Percutaneous Deep Vein Arterialization in Patients with End-Stage Peripheral Artery Disease. Vasc Endovascular Surg 2024; 58:548-553. [PMID: 38164900 DOI: 10.1177/15385744231226047] [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: 01/03/2024]
Abstract
Background: Peripheral artery disease (PAD) can present as chronic limb threatening ischemia (CLTI) with ischemic pain and tissue loss. Progression of distal disease can lead to a "no option" or end-stage disease without traditional open or endovascular revascularization due to lack of pedal targets. Innovations in endovascular technology allow for the use of percutaneous deep vein arterialization (pDVA) to treat patients with CLTI. Purpose: We describe our experience and technique for treating four patients with end-stage PAD with pDVA. Research Design: Four patients with end-stage PAD were followed during and after pDVA creation. Technical success, complications, wound healing, and freedom from major amputation were analyzed. Data Collection and Analysis: Patient data and outcomes were collected via chart review and at time of follow up appointments in vascular surgery clinic. Results: Technical success was 100%, without post-procedural complications, and patients were continued on antiplatelet and anticoagulation. Three patients (75%) had successful wound healing, with 2 patients healing after transmetatarsal amputation (TMA), and 1 healing a distal foot ulceration that did not require surgery. One patient had worsening ischemic breakdown of a TMA, despite re-intervention on the pDVA, which required a below knee amputation (BKA). Freedom from major amputation was 75% overall, with an average follow-up time of 410 days post-procedure (Range: 113-563 days). Conclusions: Percutaneous deep vein arterialization attempts to provide blood flow to the preserved venous bed in patients with end-stage PAD. Exploration and utilization of this technique continues to expand in the modern vascular era. This case series highlights 4 patients with end-stage PVD who underwent pDVA, with 100% procedural success, and 75% limb salvage rate.
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Affiliation(s)
- Krystina N Choinski
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ajit G Rao
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Prakash Krishnan
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rami O Tadros
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raman Sharma
- The Zena and Michael A Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter L Faries
- Division of Vascular Surgery, Department of Surgery, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Morii H, Inui T, Shibayama H, Oae K, Onishi F, Hashimoto T, Inokuchi K, Sawano M. Arterialization of plantar venous system via vein graft: A novel technique for reconstruction of heel pad degloving injuries. Injury 2023; 54:110826. [PMID: 37286444 DOI: 10.1016/j.injury.2023.05.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 05/10/2023] [Accepted: 05/13/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Patients with heel pad degloving injury frequently develop ischemic necrosis of the area, necessitating soft-tissue reconstruction surgery. We have developed a technique for arterialization of the plantar venous system via vein graft (APV) as the primary revascularization treatment. The objective of this study was to clarify both the utility of APV for the preservation of degloved heel pads and the impact of this preservation on clinical outcomes. METHODS Ten consecutive cases of degloving injury with devascularized heel pad were treated at a single trauma center from 2008 to 2018. Five cases underwent APV and five underwent conventional primary suture (PS) as the initial treatment. We evaluated the course according to the frequency of heel pad preservation, additional intervention after heel pad necrosis, post-operative complications, and outcomes using the Foot and Ankle Disability Index score (FADI) at the time of last follow-up. RESULTS Among the five cases that underwent APV, the heel pad was preserved in three cases and flap surgery was required in two cases. All cases that underwent PS developed necrosis of the heel pad, requiring skin graft in one case and flap surgery in four. One skin graft case and one free flap case after PS developed plantar ulcers. The three cases with preserved heel pads exhibited higher FADI than the seven cases that developed necrosis. CONCLUSION APV showed a relatively high frequency of heel pad preservation, which otherwise was uniformly lacking. Functional outcomes were improved in cases with preserved heel pad compared to those that developed necrosis and underwent additional tissue reconstruction.
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Affiliation(s)
- Hokuto Morii
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan.
| | - Takahiro Inui
- Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Hiroki Shibayama
- Department of Orthopaedic Surgery, KKR Sapporo Medical Center, Hokkaido, Japan
| | - Kazunori Oae
- Department of Orthopaedic Surgery, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Fumio Onishi
- Department of Plastic Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Takuya Hashimoto
- Department of Vascular Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Koichi Inokuchi
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Makoto Sawano
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
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Sarkar A, Nagarsheth KH. Deep Venous Arterialization for Limb Salvage. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00340-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Technical Approach to Percutaneous Femoropopliteal Bypass and Deep Vein Arterialization. Tech Vasc Interv Radiol 2022; 25:100843. [DOI: 10.1016/j.tvir.2022.100843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Twelve-Month Clinical Outcomes of Percutaneous Deep Venous Arterialization with Alternative Techniques and Ordinary Endovascular Therapy Devices for Patients with Chronic Limb-Threatening Ischemia: Results of the DEPARTURE Japan Study. Cardiovasc Intervent Radiol 2022; 45:622-632. [DOI: 10.1007/s00270-022-03095-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 02/06/2022] [Indexed: 01/24/2023]
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Eroshenko AV, Eroshkin IA, Zubova EA, Kovylov AO, Krasnoshchekova LS. Endovascular arterialization of deep crural and pedal veins in a patient with critical lower limb ischaemia. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:54-65. [PMID: 34528589 DOI: 10.33529/angio2021317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Described in the article is a clinical case report regarding complete endovascular arterialization of deep crural and pedal veins in a male patient with accompanying pathology and impossibility of intraluminal restoration of the arterial bed. Peculiarities of the presented case report consisted in creation of an arteriovenous anastomosis in the upper third of the crus using an endovascular technique. During treatment, a repeat intervention was required, i. e., balloon angioplasty of veins and implantation of an additional stent graft due to reocclusion of veins because of long-term local treatment of wounds and cytostatic therapy for background diseases (chronic myeloleukaemia and rheumatoid arthritis). The performed treatment resulted in a clear trend towards healing of the wounds on the foot and limb salvage.
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Affiliation(s)
- An V Eroshenko
- Department of Cardiovascular Surgery, Faculty of Additional Professional Education, N.I. Pirogov Russian National Research Medical University under the RF Ministry of Public Health, Moscow, Russia; Joint-Stock Company 'Clinic K+31', Moscow, Russia
| | - I A Eroshkin
- Department of Radiodiagnosis, I.M. Sechenov First Moscow State Medical University of the RF Ministry of Public Health, Moscow, Russia; N.V. Sklifosofsky Research Institute of Emergency Medicine of the Moscow Healthcare Department, Moscow, Russia
| | - E A Zubova
- Department of Emergency Cardiology, Municipal Clinical Hospital #51 of the Moscow Healthcare Department, Moscow, Russia
| | - A O Kovylov
- Endocrinological Dispensary of the Moscow Healthcare Department, Moscow, Russia
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Foot Revascularization Avoids Major Amputation in Persons with Diabetes and Ischaemic Foot Ulcers. J Clin Med 2021; 10:jcm10173977. [PMID: 34501432 PMCID: PMC8432560 DOI: 10.3390/jcm10173977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/22/2021] [Accepted: 09/02/2021] [Indexed: 11/23/2022] Open
Abstract
The study aims to evaluate the effectiveness of foot revascularization in persons with diabetic foot ulcers (DFUs) and below-the-ankle (BTA) arterial disease. Consecutive patients referred for a new active ischaemic DFU requiring lower limb revascularization were considered. Among those, only patients with a BTA arterial disease were included. Revascularization procedures were retrospectively analysed: in the case of successful foot revascularization (recanalization of pedal artery, or plantar arteries or both) or not, patients were respectively divided in two groups, successful foot perfusion (SFP) and failed foot perfusion (FFP). Healing, minor and major amputation at 12 months of follow-up were evaluated and compared. Eighty patients (80) were included. The mean age was 70.5 ± 10.9 years, 55 (68.7%) were male, 72 (90%) were affected by type 2 diabetes with a mean duration of 22.7 ± 11.3 years. Overall 45 (56.2%) patients healed, 47 (58.7%) had minor amputation and 13 (16.2%) major amputation. Outcomes for SFP and FFP were respectively: healing (89.3 vs. 9.1%, p < 0.0001), minor amputation (44.7 vs. 78.8%, p = 0.0001), major amputation (2.1 vs. 36.3%, p < 0.0001). Failed foot revascularization resulted an independent predictor of non-healing, minor amputation, and major amputation. Foot revascularization is mandatory to achieve healing and avoid major amputation in persons with ischaemic DFU and BTA arterial disease.
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Huizing E, Schreve MA, Kum S, Papageorgiou G, de Vries JPPM, de Borst GJ, Ünlü Ç. Development of a Prediction Model for the Occurrence of Stenosis or Occlusion after Percutaneous Deep Venous Arterialization. Diagnostics (Basel) 2021; 11:diagnostics11061008. [PMID: 34073045 PMCID: PMC8226684 DOI: 10.3390/diagnostics11061008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/27/2021] [Accepted: 05/29/2021] [Indexed: 11/16/2022] Open
Abstract
Percutaneous deep venous arterialization (pDVA) is a promising treatment option in patients with chronic limb-threatening ischemia. Stenosis and occlusions, which are the Achilles’ heel of every revascularization procedure, can be treated when detected early. However, frequent monitoring after pDVA is required because when stenosis or occlusions develop is unknown. Therefore, patients currently need to visit the hospital every 2 weeks for surveillance, which can be burdensome. Accordingly, we aimed to develop a model that can predict future stenosis or occlusions in patients after pDVA to be able to create tailor-made follow-up protocols. The data set included 343 peak systolic velocity and 335 volume flow measurements of 23 patients. A stenosis or occlusion developed in 17 patients, and 6 patients remained lesion-free. A statistically significant increase in the risk of stenosis or occlusion was found when duplex ultrasound values decreased 20% within 1 month. The prediction model was also able to estimate a patient-specific risk of future stenosis or occlusions. This is promising for the possibility of reducing the frequency of follow-up visits for low-risk patients and increasing the frequency for high-risk patients. These observations are the starting point for individual surveillance programs in post-pDVA patients. Future studies with a larger cohort are necessary for validation of this model.
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Affiliation(s)
- Eline Huizing
- Department of Surgery, Northwest Clinics, 1815 JD Alkmaar, The Netherlands; (M.A.S.); (Ç.Ü.)
- Correspondence:
| | - Michiel A. Schreve
- Department of Surgery, Northwest Clinics, 1815 JD Alkmaar, The Netherlands; (M.A.S.); (Ç.Ü.)
| | - Steven Kum
- Vascular Service, Department of Surgery, Changi General Hospital, Singapore 529889, Singapore;
| | - Grigorios Papageorgiou
- Department of Biostatistics, Erasmus University Medical Centre, 3015 GD Rotterdam, The Netherlands;
- Department of Epidemiology, Erasmus University Medical Centre, 3015 GD Rotterdam, The Netherlands
| | - Jean-Paul P. M. de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, 9713 GZ Groningen, The Netherlands;
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Çağdaş Ünlü
- Department of Surgery, Northwest Clinics, 1815 JD Alkmaar, The Netherlands; (M.A.S.); (Ç.Ü.)
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Marco M, Valentina I, Daniele M, Valerio DR, Andrea P, Roberto G, Laura G, Luigi U. Peripheral Arterial Disease in Persons with Diabetic Foot Ulceration: a Current Comprehensive Overview. Curr Diabetes Rev 2021; 17:474-485. [PMID: 33023453 DOI: 10.2174/1573399816999201001203111] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 11/22/2022]
Abstract
In developed countries, the prevalence of persons with diabetes and peripheral arterial disease (PAD) is approximately 50%. The presence of PAD is associated with non-healing ulcers, major amputation, cardiovascular morbidity, and mortality. It is estimated that persons with diabetes, foot ulceration and PAD have 50% of 5-years mortality rate. Therefore, subjects with ischemic diabetic foot ulcers (DFUs) should be considered a special group of patients with specific clinical characteristics, general health status and prognosis. In persons with ischemic DFUs, an early diagnosis and treatment are mandatory to reduce the risk of worse outcomes such as major amputation. Revascularization of occluded lower extremity arteries is the main treatment to restore blood flow in the foot and promote wound healing. Nonetheless, there are several unmet needs in the management of diabetic subjects with PAD and foot ulceration as medical therapy, diagnostic criteria and indications for revascularization, revascularization strategy and technical approach as well as the management of no-option critical limb ischemia patients. It is a common opinion that there is an evolution of PAD features in diabetic persons, which seems to present a more aggressive pattern. This may be related to the frequent presence of concomitant comorbidities such as renal failure which could influence the characteristics of atherosclerotic plaques and their distribution. The aim of this review is to commence a complete overview and state of the art in the treatment of patients with diabetes, PAD, and foot ulceration and to describe the current challenges and future perspectives.
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Affiliation(s)
- Meloni Marco
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Izzo Valentina
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Morosetti Daniele
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Da Ros Valerio
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Panunzi Andrea
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Gandini Roberto
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Giurato Laura
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
| | - Uccioli Luigi
- Department of Systems Medicine, University of Rome Tor Vegata, Rome, Italy
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Schreve MA, Huizing E, Kum S, de Vries JPPM, de Borst GJ, Ünlü Ç. Volume Flow and Peak Systolic Velocity of the Arteriovenous Circuit in Patients after Percutaneous Deep Venous Arterialization. Diagnostics (Basel) 2020; 10:diagnostics10100760. [PMID: 32998196 PMCID: PMC7601062 DOI: 10.3390/diagnostics10100760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/23/2020] [Accepted: 09/26/2020] [Indexed: 12/31/2022] Open
Abstract
Percutaneous deep venous arterialization (pDVA) is a developing technique for limb salvage in patients with chronic limb-threatening ischemia by creating an arteriovenous (AV) circuit. After pDVA, patency of the AV circuit is evaluated using duplex ultrasound (DUS) imaging. Peak systolic velocity (PSV) and volume flow (VF) values for maintaining a patent AV circuit are undefined; therefore, guidance about when a reintervention should be performed is lacking. The objective of this study was to interpret post-pDVA PSV and VF values in relation to AV circuit preservation. This was performed by analyzing DUS results of 22 post-pDVA patients. A total of 670 PSV and 623 VF measurements were collected. A PSV value of ≤55 cm/s and a VF value of ≤195 mL/min were found predictive for failure. The reliability of PSV and VF measurements in patent AV-circuits was good (intraclass correlation coefficient; PSV, 0.85; VF, 0.88). In conclusion, this study is the first to analyze DUS measurements in post-pDVA patients and showed that DUS can be used to anticipate for failure. The thresholds found can be used to help interpret DUS measurements in post-pDVA patients. More research in a larger patient population is needed to prospectively validate these thresholds.
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Affiliation(s)
- Michiel A. Schreve
- Department of Surgery, Northwest Clinics, 1815 JD Alkmaar, The Netherlands; (E.H.); (Ç.Ü.)
- Correspondence: ; Tel.: +31-(0)72-548-4444
| | - Eline Huizing
- Department of Surgery, Northwest Clinics, 1815 JD Alkmaar, The Netherlands; (E.H.); (Ç.Ü.)
| | - Steven Kum
- Vascular Service, Department of Surgery, Changi General Hospital, Singapore 529889, Singapore;
| | - Jean-Paul P. M. de Vries
- Division of Vascular Surgery, Department of Surgery, University Medical Centre Groningen, 9713 GZ Groningen, The Netherlands;
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Çağdaş Ünlü
- Department of Surgery, Northwest Clinics, 1815 JD Alkmaar, The Netherlands; (E.H.); (Ç.Ü.)
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Chavkin NW, Hirschi KK. Single Cell Analysis in Vascular Biology. Front Cardiovasc Med 2020; 7:42. [PMID: 32296715 PMCID: PMC7137757 DOI: 10.3389/fcvm.2020.00042] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 03/05/2020] [Indexed: 12/12/2022] Open
Abstract
The ability to quantify DNA, RNA, and protein variations at the single cell level has revolutionized our understanding of cellular heterogeneity within tissues. Via such analyses, individual cells within populations previously thought to be homogeneous can now be delineated into specific subpopulations expressing unique sets of genes, enabling specialized functions. In vascular biology, studies using single cell RNA sequencing have revealed extensive heterogeneity among endothelial and mural cells even within the same vessel, key intermediate cell types that arise during blood and lymphatic vessel development, and cell-type specific responses to disease. Thus, emerging new single cell analysis techniques are enabling vascular biologists to elucidate mechanisms of vascular development, homeostasis, and disease that were previously not possible. In this review, we will provide an overview of single cell analysis methods and highlight recent advances in vascular biology made possible through single cell RNA sequencing.
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Affiliation(s)
- Nicholas W Chavkin
- Department of Cell Biology, Developmental Genomics Center, School of Medicine, University of Virginia, Charlottesville, VA, United States
| | - Karen K Hirschi
- Department of Cell Biology, Developmental Genomics Center, School of Medicine, University of Virginia, Charlottesville, VA, United States.,Departments of Medicine and Genetics, Cardiovascular Research Center, School of Medicine, Yale University, New Haven, CT, United States
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Sharma A. Current review with evolving management strategies in critical limb ischemia. Indian J Radiol Imaging 2019; 29:258-263. [PMID: 31741593 PMCID: PMC6857262 DOI: 10.4103/ijri.ijri_208_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/20/2019] [Accepted: 06/25/2019] [Indexed: 01/09/2023] Open
Abstract
Critical limb ischemia represents the end stage of peripheral artery disease, which is associated with impaired quality of life and considerable morbidity and mortality. Economical impact of the disease is huge with a substantial burden on patients, healthcare providers, and resources. Varied therapeutic strategies have been employed in the management of these patients. These patients usually have complex multilevel occlusive arteriopathy with significant comorbidities, rendering surgical interventions undesirable in many cases. Recent therapeutic advances with evolving endovascular techniques and gene or cell-based therapies have the potential to dramatically change the therapeutic outlook in these patients.
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Affiliation(s)
- Arun Sharma
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, India
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