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Lee BC, Oh DS, Lee HS, Kim SH, Park JH, Lee KH, Kim HJ, Yang JH, Lee SE. Leriche Syndrome Misdiagnosed as Complex Regional Pain Syndrome in a Patient with Neuropathic Pain Caused by a Chip Fracture: A Case Report. ACTA ACUST UNITED AC 2021; 57:486. [PMID: 34066172 DOI: 10.3390/medicina57050486] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 11/26/2022]
Abstract
Introduction: Leriche syndrome is an aortoiliac occlusive disease caused by atherosclerotic occlusion. We report a case of Leriche syndrome with a fracture that was suspected as complex regional pain syndrome (CRPS), as the post-traumatic pain gradually worsened in the form of excruciating neuropathic pain. Case Report: A 52-year-old woman with a history of hypertension was referred to the Department of Pain Medicine from a local orthopedic clinic because of suspected CRPS for excruciating neuropathic pain for one month. She complained of gait dysfunction and severe pain in the right foot following an incident of trauma with the right first toe. The average pain intensity assessed using the visual analog scale (VAS) was 90 (0: no pain, 100: the worst pain imaginable), and the neuropathic pain was evident as a score of 6/10 on Douleur neuropathique 4. Allodynia, hyperalgesia, blue discoloration of the skin, asymmetric temperature change (1.38 °C), and edematous soft tissue changes were observed. Ultrasonography showed a chip fracture in the first distal phalanx of the right first toe. The diagnosis was most probably CRPS type I according to the Budapest research criteria for CRPS. However, multiple pain management techniques were insufficient in controlling the symptoms. A month and a half later, an ankle-brachial index score of less than 0.4 suggested severe peripheral artery disease. Computed tomography angiography showed total occlusion between the infrarenal abdominal aorta and the bilateral common iliac arteries. Therefore, she underwent aortic-bifemoral bypass surgery with a diagnosis of Leriche syndrome. Three months after the surgery, the average pain intensity was graded as 10 on the VAS (0–100), the color of the skin of the right first toe improved and no gait dysfunction was observed. Conclusion: A chip fracture in a region with insufficient blood flow could manifest as excruciating neuropathic pain in Leriche syndrome.
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Abstract
Diabetic foot ulcers (DFUs) are a common but highly morbid complication of long-standing diabetes, carrying high rates of associated major amputation and mortality. As the global incidence of diabetes has increased, along with the lifespan of the diabetic patient, the worldwide burden of DFUs has grown steadily. Outcomes in diabetes and DFUs are known to depend strongly on social determinants of health, with worse outcomes noted in minority and socioeconomically disadvantaged populations. Effective treatment of DFUs is complex, requiring considerable expenditure of resources and significant cost to the health care system. Comprehensive care models with multidisciplinary teams have proven effective in the treatment of DFUs by decreasing barriers to care and increasing access to the multiple specialists required to provide timely and effective DFU procedural intervention, surveillance, and preventative care. Vascular surgeons are an integral part throughout the cycle of care for DFUs and should be involved early in the course of such patients to maximize their contributions to a multidisciplinary care model.
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Affiliation(s)
- Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins Medical Institutions, Halsted 671, 600 N Wolfe Street, Baltimore, MD 21287
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins Medical Institutions, Halsted 671, 600 N Wolfe Street, Baltimore, MD 21287.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Misra S, Shishehbor MH, Takahashi EA, Aronow HD, Brewster LP, Bunte MC, Kim ESH, Lindner JR, Rich K. Perfusion Assessment in Critical Limb Ischemia: Principles for Understanding and the Development of Evidence and Evaluation of Devices: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e657-e672. [PMID: 31401843 DOI: 10.1161/cir.0000000000000708] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There are >12 million patients with peripheral artery disease in the United States. The most severe form of peripheral artery disease is critical limb ischemia (CLI). The diagnosis and management of CLI is often challenging. Ethnic differences in comorbidities and presentation of CLI exist. Compared with white patients, black and Hispanic patients have higher prevalence rates of diabetes mellitus and chronic renal disease and are more likely to present with gangrene, whereas white patients are more likely to present with ulcers and rest pain. A thorough evaluation of limb perfusion is important in the diagnosis of CLI because it can not only enable timely diagnosis but also reduce unnecessary invasive procedures in patients with adequate blood flow or among those with other causes for ulcers, including venous, neuropathic, or pressure changes. This scientific statement discusses the current tests and technologies for noninvasive assessment of limb perfusion, including the ankle-brachial index, toe-brachial index, and other perfusion technologies. In addition, limitations of the current technologies along with opportunities for improvement, research, and reducing disparities in health care for patients with CLI are discussed.
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Salaun P, Desormais I, Lapébie FX, Rivière AB, Aboyans V, Lacroix P, Bataille V, Constans J, Boulon C. Comparison of Ankle Pressure, Systolic Toe Pressure, and Transcutaneous Oxygen Pressure to Predict Major Amputation After 1 Year in the COPART Cohort. Angiology 2018; 70:229-236. [DOI: 10.1177/0003319718793566] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The hemodynamic definition of critical limb ischemia (CLI) has evolved over time but remains controversial. We compared the prediction of major amputation by 3 hemodynamic methods. Patients were selected from the Cohorte des Patients ARTériopathes cohort of patients hospitalized for peripheral arterial disease. Patients with CLI were enrolled according to the Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease II definition and followed up for at least 1 year. We compared the major amputation rate according to initial ankle pressure (AP), systolic toe pressure (STP), and forefoot transcutaneous oxygen pressure (TcPO2); 556 patients were included and divided into surgical (264) and medical (292) groups. The AP failed to identify 42% of patients with CLI. After 1 year, 27% of medical and 17% of surgical patients had undergone major amputation. The TP <30 mm Hg predicted major amputation in the whole sample and in the medical group (odds ratio [OR] 3.5 [1.7-7.1] and OR 5 [2-12.4], respectively), but AP did not. The TcPO2 <10 mm Hg also predicted major amputation (OR 2.3 [1.5-3.5] and OR 3.8 [2.1-6.8]). The best predictive thresholds to predict major amputation were STP <30 mm Hg and TcPO2 <10 mm Hg. None of these methods performed before surgery was able to predict outcome in the revascularized patients.
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Affiliation(s)
- Pierre Salaun
- Médecine vasculaire, Hôpital St Andre, Bordeaux, France
| | | | | | | | - Victor Aboyans
- Service de Cardiologie, Hôpital Universitaire Dupuytren, CHU de Limoges, Imoges, France
| | | | - Vincent Bataille
- Stroma Lab UMR 5273/INSERM U1031, Toulouse, France
- Université de Toulouse III, Toulouse, France
| | - Joël Constans
- Médecine vasculaire, Hôpital St Andre, Bordeaux, France
| | - Carine Boulon
- Médecine vasculaire, Hôpital St Andre, Bordeaux, France
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Wickström JE, Laivuori M, Aro E, Sund RT, Hautero O, Venermo M, Jalkanen J, Hakovirta H. 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] [What about the content of this article? (0)] [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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Yaşar E, Tok F, Kesikburun S, Ada AM, Kelle B, Göktepe AS, Yazıcıoğlu K, Tan AK. Epidemiologic data of trauma-related lower limb amputees: A single center 10-year experience. Injury 2017; 48:349-52. [PMID: 28038786 DOI: 10.1016/j.injury.2016.12.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/11/2016] [Accepted: 12/21/2016] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this study is three fold: 1) to introduce epidemiologic data of patients with trauma-related amputations as a 10-year experience of a rehabitation center; 2) to determine comorbidities and secondary conditions of lower limb loss; 3) to determine the rehospitalization reasons for lower limb amputee patients. MATERIALS AND METHODS This retrospective study was conducted in a tertiary rehabilitation center in Turkey. Clinical and demographic data of amputees including sex, age, employment status, time since amputation, time after amputation to first hospitalization, length of hospitalization, how many times the patient was hospitalized, reason for hospitalization, stump complications, comorbid conditions, amputation level and K classifacation were documented. RESULTS Three hundred ninetynine patients with a mean age of 23,48±6,04 (4-74) years were included in this study. Mean duration after amputation was 119,71±68,86months. Patients were 3,43±2,53 times hospitalized. Landmine explosion was the most common etiology of amputation with 370 patients (92.7%). Below knee amputation was the most common amputation level with 230 (50,77%) amputations. 399 patients were hospitalized 1369 times and the most common hospitalization reason were stump complications (356 times, 26,00%). Spur formation (202 times) was the most common stump complications. Pyscologic disorders were the most common comorbidity with 68 patient (37,56%). CONCLUSION Patients with traumatic limb amputations are likely to experience several complications and comorbidities. Prevention of secondary conditions affecting those living with the loss of a limb is an important part of amputee rehabilitation and may prevent rehospitalization.
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Shirasu T, Hoshina K, Akagi D, Miyahara T, Yamamoto K, Watanabe T. Pulse volume recordings to identify falsely elevated ankle brachial index. Asian Cardiovasc Thorac Ann 2016; 24:517-22. [DOI: 10.1177/0218492316651527] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Ankle brachial index can be falsely elevated in cases of medial arterial calcification, and its clinical use should be limited, especially in patients with diabetes. The aim of this study was to evaluate the potential role of pulse volume recording in detecting falsely elevated ankle brachial index. Methods Two parameters of the pulse waveform were automatically calculated: upstroke time and percentage mean artery pressure. Pulse volume recordings were retrospectively evaluated in 171 consecutive patients (342 limbs); 73 (43%) had a diagnosis of diabetes. Results On multivariate analysis, diabetes (hazard ratio = 1.7), ankle brachial index ≤ 0.90 (hazard ratio = 4.4), upstroke time ≥ 180 ms (hazard ratio = 2.1), and percentage mean artery pressure ≥ 45% (hazard ratio = 2.8) were significantly related to toe brachial index < 0.60. Further analysis for falsely elevated ankle brachial index was performed in 196 limbs (146 patients) with ankle brachial index > 0.90. The difference between ankle brachial index and toe brachial index differentiated the limbs of diabetic patients, with percentage mean artery pressure ≥ 45%, from controls (0.45 ± 0.17 vs. 0.35 ± 0.16, p = 0.03); upstroke time was not found to be a discriminating factor. Conclusions Although measurement of ankle brachial index remains the gold standard for diagnosing peripheral arterial disease, percentage mean artery pressure, automatically obtained in ankle brachial index measurement, may be useful to detect falsely elevated ankle brachial index, especially in patients with diabetes.
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Affiliation(s)
- Takuro Shirasu
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsuyuki Hoshina
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Daisuke Akagi
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takuya Miyahara
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kota Yamamoto
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshiaki Watanabe
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Vallabhaneni R, Kalbaugh CA, Kouri A, Farber MA, Marston WA. Current accepted hemodynamic criteria for critical limb ischemia do not accurately stratify patients at high risk for limb loss. J Vasc Surg 2016; 63:105-12. [PMID: 26412436 DOI: 10.1016/j.jvs.2015.07.095] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/26/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Critical limb ischemia (CLI) has been defined as rest pain or tissue loss in patients who have an ankle-brachial index (ABI) ≤0.50, ankle pressure (AP) <70 mm Hg, or toe pressure (TP) <50 mm Hg. Data suggesting that these patients are at high risk for limb loss without successful revascularization are limited. This study was designed to identify limb loss and mortality rates in patients who did not respond to revascularization or who were not revascularized to determine whether CLI hemodynamic criteria accurately identify patients at high risk for limb loss. METHODS Between 2008 and 2010, all patients undergoing lower extremity arterial duplex ultrasound testing at our hospital were identified. Those with ABI <0.50, AP <70 mm Hg, or TP <50 mm Hg were retrospectively reviewed to determine whether they had symptoms of rest pain, ischemic ulceration, or gangrene qualifying them for analysis in the database. Patients who underwent revascularization and subsequently had postrevascularization ABI, AP, or TP greater than the CLI criteria were removed from the cohort. Demographic factors, wound healing, amputation rates, and mortality were obtained and analyzed in relation to the initial APs and TPs. Outcomes were measured by Kaplan-Meier life-table analysis and Cox proportional hazards models. RESULTS In 381 patients identified in the study, 443 limbs met CLI criteria. After revascularization, 98 limbs with ABI or TP that improved to >0.5 and >50 mm Hg, respectively, were removed from the study cohort. In 45 limbs, patients did not respond to initial revascularization as their ABI, AP, or TP remained within CLI criteria. These limbs remained in the patient cohort, yielding a final group of 296 patients and 345 limbs. Mean follow-up was 2 years. In the entire patient cohort, limb loss occurred in 24% at 1 year and in 31% at 3 years. Mortality was 32% at 1 year and 56% at 3 years. Amputation-free survival was 54% at 1 year and 28% at 3 years. Lower TPs were associated with a statistically higher incidence of amputation. Among those with an initial TP ≤10 mm Hg (n = 85), limb loss occurred in 46% at 1 year and 60% at 3 years. This limb loss was significantly greater than limb loss among those with a TP of 31 to 50 mm Hg (n = 115; 18% at 3 years; P < .001) Amputation-free survival in patients with a TP ≤10 mm Hg was 8% at 3 years. CONCLUSIONS CLI is associated with a high mortality, but not all patients with currently defined hemodynamic criteria for CLI are at high risk of limb loss. Patients with a TP between 31 and 50 mm Hg (41% of the cohort) and not receiving revascularization or not responding hemodynamically to revascularization experienced a low risk of limb loss. We recommend revising the hemodynamic criteria for CLI to better identify patients at high risk for limb loss who require intervention to improve outcomes.
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Abstract
Patients with critical limb ischemia usually have severe atherosclerotic disease and are at a high risk of limb loss as well as major adverse cardiovascular events. The current article provides a description of the clinical presentation of patients with critical limb ischemia and also discusses the initial evaluation of these patients, including physical examination, use of noninvasive vascular tests, and other imaging modalities. An overview of the general management of these patients is also provided, including the identification of patients who benefit from revascularization or primary amputation, principles of wound care, and therapies for cardiovascular risk reduction.
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Affiliation(s)
| | - Phillip A Erwin
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
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Høyer C, Sandermann J, Petersen LJ. The toe-brachial index in the diagnosis of peripheral arterial disease. J Vasc Surg 2013; 58:231-8. [DOI: 10.1016/j.jvs.2013.03.044] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 03/13/2013] [Accepted: 03/24/2013] [Indexed: 11/23/2022]
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Bundó M, Urrea M, Muñoz L, Llussà J, Forés R, Torán P. Correlación entre los índices dedo-brazo y tobillo-brazo en pacientes con diabetes mellitus tipo 2. Med Clin (Barc) 2013; 140:390-4. [DOI: 10.1016/j.medcli.2012.03.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 02/26/2012] [Accepted: 03/01/2012] [Indexed: 11/29/2022]
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Emler C, Jacomella V, Rufibach K, Thalhammer C, Amann-Vesti BR, Husmann M. Pressure Indices in Peripheral Arterial Disease Assessed by Infrared Photosensors. Angiology 2012; 64:93-7. [DOI: 10.1177/0003319712448248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Charlotte Emler
- Clinic for Angiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Kaspar Rufibach
- Division of Biostatistics, Institute of Social and Preventive Medicine, University of Zurich, Switzerland
| | | | | | - Marc Husmann
- Clinic for Angiology, University Hospital Zurich, Zurich, Switzerland
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Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, Golzarian J, Gornik HL, Halperin JL, Jaff MR, Moneta GL, Olin JW, Stanley JC, White CJ, White JV, Zierler RE. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline). Vasc Med 2012; 16:452-76. [PMID: 22128043 DOI: 10.1177/1358863x11424312] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, Golzarian J, Gornik HL, Halperin JL, Jaff MR, Moneta GL, Olin JW, Stanley JC, White CJ, White JV, Zierler RE. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery. Catheter Cardiovasc Interv 2012; 79:501-31. [PMID: 21960485 PMCID: PMC4505549 DOI: 10.1002/ccd.23373] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Cao P, Eckstein HH, De Rango P, Setacci C, Ricco JB, de Donato G, Becker F, Robert-Ebadi H, Diehm N, Schmidli J, Teraa M, Moll FL, Dick F, Davies AH, Lepäntalo M, Apelqvist J. Chapter II: Diagnostic methods. Eur J Vasc Endovasc Surg 2011; 42 Suppl 2:S13-32. [PMID: 22172470 DOI: 10.1016/S1078-5884(11)60010-5] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Non-invasive vascular studies can provide crucial information on the presence, location, and severity of critical limb ischaemia (CLI), as well as the initial assessment or treatment planning. Ankle-brachial index with Doppler ultrasound, despite limitations in diabetic and end-stage renal failure patients, is the first-line evaluation of CLI. In this group of patients, toe-brachial index measurement may better establish the diagnosis. Other non-invasive measurements, such as segmental limb pressure, continuous-wave Doppler analysis and pulse volume recording, are of limited accuracy. Transcutaneous oxygen pressure (TcPO(2)) measurement may be of value when rest pain and ulcerations of the foot are present. Duplex ultrasound is the most important non-invasive tool in CLI patients combining haemodynamic evaluation with imaging modality. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are the next imaging studies in the algorithm for CLI. Both CTA and MRA have been proven effective in aiding the decision-making of clinicians and accurate planning of intervention. The data acquired with CTA and MRA can be manipulated in a multiplanar and 3D fashion and can offer exquisite detail. CTA results are generally equivalent to MRA, and both compare favourably with contrast angiography. The individual use of different imaging modalities depends on local availability, experience, and costs. Contrast angiography represents the gold standard, provides detailed information about arterial anatomy, and is recommended when revascularisation is needed.
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Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, Golzarian J, Gornik HL, Halperin JL, Jaff MR, Moneta GL, Olin JW, Stanley JC, White CJ, White JV, Zierler RE. 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline). Circulation 2011; 124:2020-45. [DOI: 10.1161/cir.0b013e31822e80c3] [Citation(s) in RCA: 272] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Alan T. Hirsch
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
| | - Sanjay Misra
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
- Society of Interventional Radiology Representative
| | | | - Joshua A. Beckman
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
- Society for Vascular Medicine Representative
| | | | | | - Heather L. Gornik
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
- ACCF/AHA Representative
| | - Jonathan L. Halperin
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
- ACCF/AHA Task Force on Practice Guidelines Liaison
| | - Michael R. Jaff
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
- ACCF/AHA Representative
| | | | - Jeffrey W. Olin
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
- ACCF/AHA Task Force on Performance Measures Liaison
| | | | - Christopher J. White
- Writing group members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
- Society for Cardiovascular Angiography and Interventions Representative
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Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, Golzarian J, Gornik HL, Halperin JL, Jaff MR, Moneta GL, Olin JW, Stanley JC, White CJ, White JV, Zierler RE. 2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2011; 58:2020-45. [PMID: 21963765 DOI: 10.1016/j.jacc.2011.08.023] [Citation(s) in RCA: 450] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Rooke TW, Hirsch AT, Misra S, Sidawy AN, Beckman JA, Findeiss LK, Golzarian J, Gornik HL, Halperin JL, Jaff MR, Moneta GL, Olin JW, Stanley JC, White CJ, White JV, Zierler RE. 2011 ACCF/AHA focused update of the guideline for the management of patients with peripheral artery disease (updating the 2005 guideline): a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, and Society for Vascular Surgery. J Vasc Surg 2011; 54:e32-58. [PMID: 21958560 DOI: 10.1016/j.jvs.2011.09.001] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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22
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Imagama S, Matsuyama Y, Sakai Y, Ito Z, Wakao N, Deguchi M, Hachiya Y, Osawa Y, Yoshihara H, Kamiya M, Kanemura T, Kato F, Yukawa Y, Yoshida T, Harada A, Kawakami N, Suzuki K, Matsubara Y, Goto M, Sato K, Ito S, Maruyama K, Yanase M, Ishida Y, Kuno N, Hasegawa T, Ishiguro N. An arterial pulse examination is not sufficient for diagnosis of peripheral arterial disease in lumbar spinal canal stenosis: a prospective multicenter study. Spine (Phila Pa 1976) 2011; 36:1204-10. [PMID: 21217453 DOI: 10.1097/BRS.0b013e3181ebd86f] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective, multicenter study. OBJECTIVE To conduct peripheral arterial disease (PAD) screening on intermittent claudication (IC) in patients with lumbar spinal canal stenosis (LSCS) to examine the relationships among combined LSCS and PAD, symptoms, and physical findings. SUMMARY OF BACKGROUND DATA IC occurs due to two underlying diseases, LSCS and PAD, and has an increasing prevalence with the aging of society. Reliable diagnosis of PAD is critical for appropriate conservative management of IC patients with LSCS in an Orthopedic Surgery Outpatient Department (OSOPD). METHODS PAD tests were prospectively conducted in 201 patients with IC and LSCS who initially visited an OSOPD at a hospital affiliated with the Nogoya Spine Group. Occurrence of PAD as a complication was assessed using ankle brachial pressure index (ABI) and toe brachial pressure index (TBI) tests. PAD was diagnosed in patients with ABI ≤ 0.9 or TBI ≤ 0.6, and the relationship of the occurrence of PAD with symptoms and physical findings such as abnormal arterial pulses was investigated. RESULTS Combined LSCS and PAD was found in 52 patients (26%), with 45 cases (22%) diagnosed on the basis of TBI test in patients with a normal ABI. Of the patients with PAD, many suffered from risk factors for PAD, with a significantly higher frequency of PAD in patients with hyperlipidemia (P < 0.05). PAD also occurred significantly more frequently in patients with abnormal pulses in the popliteal (P < 0.05), posterior tibial (P < 0.0001), and dorsal pedis (P < 0.0001) arteries; however, the sensitivity of these tests for PAD diagnosis was relatively low, at 34%, 60% and 68%, respectively. CONCLUSION The results of the prospective study define the rate of occurrence of combined LSCS and PAD using ABI and TBI tests for the first time, and the findings suggest that screening for PAD should be conducted in LSCS patients. ABI and TBI tests are necessary for PAD screening in outpatients, whereas observation of the arterial pulse in the lower extremities is necessary but not sufficient for PAD diagnosis.
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Abstract
The timely and accurate noninvasive assessment of peripheral arterial disease (PAD) is a critical component of a limb preservation initiative in patients with diabetes mellitus. Noninvasive vascular studies (NIVS) can be useful in screening patients with diabetes for PAD. In patients with clinical signs or symptoms, NIVS provide crucial information on the presence, location, and severity of PAD, as well as an objective assessment of the potential for primary healing of an index wound or a surgical incision. Appropriately-selected NIVS are important in the decision-making process to determine whether and what type of intervention might be most appropriate, given the clinical circumstances. Hemodynamic monitoring is likewise very important following either an endovascular procedure or a surgical bypass. Surveillance studies, usually with a combination of physiologic testing and imaging with duplex ultrasound, accurately identify recurrent disease prior to the occurrence of thrombosis, allowing targeted reintervention. NIVS can be broadly grouped into three general categories: physiologic or hemodynamic measurements; anatomic imaging; and measurements of tissue perfusion. These types of tests and suggestions for their appropriate application in patients with diabetes are reviewed.
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Bonham PA, Kelechi T, Mueller M, Robison J. Are Toe Pressures Measured by a Portable Photophlethysmograph Equivalent to Standard Laboratory Tests? J Wound Ostomy Continence Nurs 2010; 37:475-86. [DOI: 10.1097/won.0b013e3181eda0c5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rosero EB, Kane K, Clagett GP, Timaran CH. A systematic review of the limitations and approaches to improve detection and management of peripheral arterial disease in Hispanics. J Vasc Surg 2010; 51:27S-35S. [DOI: 10.1016/j.jvs.2009.08.085] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 08/20/2009] [Accepted: 08/23/2009] [Indexed: 11/25/2022]
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Abstract
Although neuropathic ulceration remains the commonest type of foot ulcers among patients with diabetes, recent data suggest that ischemic (and therefore, neuroischemic) ulcers are on the rise. The high prevalence and incidence of diabetes and its attendant foot complications, coupled with the current trend where increasingly diabetes care is being provided by general practitioners (primary care physicians) would mean that primary care practices are expected to see greater numbers of diabetic foot ulcer patients. Unfortunately, these settings are frequently ill-equipped to appropriately manage diabetic foot ulcers either due to lack of adequately trained personnel and access to multidisciplinary foot care teams. Whereas neuropathic foot ulceration may appear to be less challenging, neuroischemic or ischemic ulcers portend a higher risk of adverse outcomes, including non-healing, infection, amputation, and death. The last 2 decades have witnessed a paradigm shift from neuropathy as the main etiological factor in diabetic foot disease to an ever-increasing preponderance of ischemic and/or neuroischemic ulceration. Available literature does not always consider the limited access primary care practices have to specialized multidisciplinary foot care teams. Additionally, in the case of neuroischemic and/or ischemic ulcers, existing guidelines on their diagnosis and management are varied and unclear. This review aimed at providing a simple understanding to the complex evidence base for diagnosing and treating neuroischemic and/or ischemic ulcers in a primary care setting. It emphasizes the need for urgent vascular review in all patients with ischemic/ neuroischemic ulcers and advocates effective participation of vascular specialists in diabetic foot clinics and combined ward rounds.
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Abstract
Peripheral arterial disease (PAD), a manifestation of systemic atherosclerosis, is a significant health problem. It manifests in lower extremities as intermittent claudication, limb ischemia, or gangrene and other locations as stroke, renal failure, or mesenteric ischemia. Fontaine and Rutherford classifications are the 2 commonly used classifications to stage the severity of PAD. The diagnostic tools include ankle-brachial index, a valuable tool in diagnosing lower extremity PAD, and a treadmill test. Other useful diagnostic tools include the San Diego Claudication Questionnaire to screen patients for symptoms and imaging modalities such as duplex scan, angiogram, computer tomographic angiogram, and magnetic resonance angiogram. Medical management of PAD involves comprehensive care, including risk factor modification of etiologies predisposing to atherosclerosis. These involve using antiplatelet therapy with aspirin or clopidogrel, controlling hypertension, managing hypercholesterolemia, and using vasodilators such as cilostazol. Exercise rehabilitation is an efficacious approach to improve intermittent claudication and should be recommended to each patient. Revascularization therapy is indicated for those who have critical limb ischemia or severe claudication not improved by medical management. Revascularization consists of endovascular techniques to open up the vessel and traditional bypass surgery to bypass the diseased segment. Recent published guidelines detailing recommendations on different treatment modalities in patients with PAD are described.
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Bonham PA, Cappuccio M, Hulsey T, Michel Y, Kelechi T, Jenkins C, Robison J. Are ankle and toe brachial indices (ABI-TBI) obtained by a pocket Doppler interchangeable with those obtained by standard laboratory equipment? J Wound Ostomy Continence Nurs 2007; 34:35-44. [PMID: 17228206 DOI: 10.1097/00152192-200701000-00007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was to determine if the ankle and toe brachial indices obtained by an experienced registered nurse (RN) using a pocket Doppler were within acceptable levels of agreement with those obtained by a registered vascular technologist (RVT) using standard laboratory equipment. DESIGN A within-subjects comparative design was used. SETTING AND SUBJECTS Thirty subjects who were referred to a vascular laboratory for arterial studies were recruited. All tests were performed in the outpatient vascular laboratory of a large, urban medical center. METHODOLOGY Ankle and toe brachial indices were measured on each subject by the RN and the RVT during each visit. Data were analyzed using the Bland-Altman method to assess the level of agreement between the RN's pocket Doppler and the RVT's standard laboratory equipment. RESULTS Differences between each instrument's ankle brachial indices were within the a priori 15% limit of agreement. Differences between each instrument's toe brachial indices exceeded the a priori 15% limit of agreement. CONCLUSION The ankle brachial index obtained by using a pocket Doppler by an experienced RN is interchangeable with vascular laboratory testing for detection of lower extremity arterial disease (LEAD). The pocket Doppler-derived toe brachial index was not interchangeable with vascular laboratory testing for detection of LEAD.
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Affiliation(s)
- Phyllis A Bonham
- Wound Care Education Program, College of Nursing, Medical University of South Carolina, Charleston 29425, USA.
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Marui A, Tabata Y, Kojima S, Yamamoto M, Tambara K, Nishina T, Saji Y, Inui KI, Hashida T, Yokoyama S, Onodera R, Ikeda T, Fukushima M, Komeda M. A Novel Approach to Therapeutic Angiogenesis for Patients With Critical Limb Ischemia by Sustained Release of Basic Fibroblast Growth Factor Using Biodegradable Gelatin Hydrogel An Initial Report of the Phase I-IIa Study. Circ J 2007; 71:1181-6. [PMID: 17652878 DOI: 10.1253/circj.71.1181] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Limb ischemia remains a challenge. To overcome shortcomings or limitations of gene therapy or cell transplantation, a sustained release system of basic fibroblast growth factor (bFGF) using biodegradable gelatin hydrogel has been developed. METHODS AND RESULTS A phase I-IIa study was performed, in which 7 patients had critical limb ischemia. They were intramuscularly injected with 200 microg of bFGF-incorporated gelatin hydrogel microspheres into the gastrocnemius of the ischemic limb. End-points were safety and feasibility of treatment after 4 and 24 weeks. One patient was excluded from the study for social reasons, but only after symptomatic improvements. In the evaluation of the other 6 patients, significant improvements were observed in the distance walked in 6 min (295+/-42 m vs 491+/-85 m for pretreatment vs after 24 weeks, p=0.023) and in transcutaneous oxygen pressure (53.5+/-5.2 mmHg vs 65.5+/-4.0 mmHg, p=0.03). The rest pain scale also improved (3.5+/-0.2 vs 1.0+/-0.6, p=0.022). The ankle-brachial pressure index improved at 4 weeks but not at 24 weeks. Among 5 patients who had a non-healing foot ulcer, the ulcer was completely healed in 3 patients, reduced in 1, and there was no change in 1 patient at 24 weeks. The blood levels of bFGF were undetected or within the normal level in all patients. CONCLUSIONS The sustained release of bFGF from gelatin hydrogel might be simple, safe, and effective to achieve therapeutic angiogenesis because it did not need genetic materials or collection of implanted cells, and because it did not have any general effects, which was supported by there being no elevation of the bFGF serum level.
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Affiliation(s)
- Akira Marui
- Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, and Department of Pharmacy, Kyoto University Hospital, Japan
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Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WRC, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006; 113:e463-654. [PMID: 16549646 DOI: 10.1161/circulationaha.106.174526] [Citation(s) in RCA: 2155] [Impact Index Per Article: 119.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, Hiratzka LF, Murphy WR, Olin JW, Puschett JB, Rosenfield KA, Sacks D, Stanley JC, Taylor LM, White CJ, White J, White RA, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Gibbons RJ, Halperin JL, Hiratzka LF, Hunt SA, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic): A Collaborative Report from the American Association for Vascular Surgery/Society for Vascular Surgery,⁎Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). J Am Coll Cardiol 2006. [DOI: 10.1016/j.jacc.2006.02.024] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
Lower extremity arterial disease affects approximately one third of individuals 66 years of age and older and has a high risk for nonhealing wounds, infection, and limb loss. Much wound care is given by or under the direction of nurses. Therefore, the assessment and management of these patients presents many opportunities and challenges. Assessment is the cornerstone of effective care, but traditional methods of lower extremity arterial assessment, such as pulse palpation and pain history, are insufficient to determine the presence and extent of ischemia. Recently published national guidelines for assessment and management of patients with lower extremity wounds have recommended using noninvasive tests such as the ankle brachial index and toe brachial index to rule out lower extremity arterial disease, which complicates wound healing. However, the ankle brachial index can be falsely elevated in patients with diabetes and renal failure because of calcification of the arteries, which causes them to be incompressible. In these situations, it has been advised to obtain a toe pressure or toe brachial index because digital arteries are usually less affected by calcification. There is a paucity of data about the knowledge of principles and performance of the ankle brachial index/toe brachial index by nurses, particularly in the United States, using pocket-sized portable Doppler equipment. Therefore, the purpose of this article is to provide an overview and synthesis of relevant studies and published expert opinion regarding noninvasive arterial assessment using ankle brachial and toe brachial indexes as a basis for developing protocols for performing the tests and identifying gaps in research where further investigation is needed.
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Affiliation(s)
- Phyllis A Bonham
- Wound Care Education Program, College of Nursing, Medical University of South Carolina, South Carolina, USA.
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Abstract
Amputation may be the most appropriate therapy for an ischemic or infected limb, but the level at which to amputate is often difficult to determine. Selecting the appropriate level is crucial when performing an amputation. The goals of surgery are to maintain maximal limb length and ensure successful healing. When more of the foot and limb can be preserved, the chances for rehabilitation are improved. This article reviews how to determine the most appropriate level of amputation.
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Affiliation(s)
- Robert W Zickler
- Division of Vascular Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey, PO Box 1709, Newark, NJ 07101, USA.
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Abstract
A prospective analysis was conducted to identify structural and biomechanical first ray abnormalities in consecutive diabetic patients presenting with their first great toe ulcer. Twenty-six patients (33 feet) met the inclusion criteria, with seven patients having bilateral hallux ulcers. There was no other history of ulcer, trauma, or surgery on the respective limb. Data were obtained during the patients' initial presentation with a great toe ulcer and included verbal history, standardized weight bearing radiographs, and standardized objective clinical measurements. Four patients (four feet) with subungual ulcers were included because of mechanical etiology. Twenty-four of the remaining 29 involved limbs exhibited gastrocnemius/soleus equinus and two other limbs had gastrocnemius equinus. Twenty-eight of 29 had structural hallux limitus. Twenty-four had hallux interphalangeal abductus. Twenty of the 33 ulcers were located plantar-medially at the interphalangeal joint area. Other frequent findings were first ray elevatus or dorsiflexion deformity (18 of 29), functional hallux limitus (14 of 29), interphalangeal joint sesamoid bone (13 of 29), hyperextended interphalangeal joint (13 of 29), and a prominent plantar-medial condyle of the proximalaspect of the distalphalanx (7 of 29). Halluxmalleus was less common (4 of 29), but consistently associated with plantar-distal tip ulceration. Metatarsus primus adductus was also infrequent (6 of 29). This study identifies and illustrates the importance of several biomechanical and structural factors present on initial presentation of great toe ulcers. Addressing these factors may improve the success of treatment and lessen the occurrence of this common and complex problem.
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Affiliation(s)
- Troy J Boffeli
- Department of Surgery, Regions Hospital, 640 Jackson St., St. Paul, MN 55101, USA.
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Affiliation(s)
- G Patrick Clagett
- Division of Vascular Surgery, University of Texas Southwestern Medical Center, Dallas 75390-9157, USA
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