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Kyselovic J, Adamičková A, Gažová A, Valášková S, Chomaničová N, Červenák Z, Madaric J. Atorvastatin Treatment Significantly Increased the Concentration of Bone Marrow-Derived Mononuclear Cells and Transcutaneous Oxygen Pressure and Lowered the Pain Scale after Bone Marrow Cells Treatment in Patients with "No-Option" Critical Limb Ischaemia. Biomedicines 2024; 12:922. [PMID: 38672276 PMCID: PMC11048671 DOI: 10.3390/biomedicines12040922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 03/20/2024] [Revised: 04/12/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND The present study investigated the outcomes and possible predictive factors of autologous bone marrow cells (BMCs) therapy in patients with "no-option" critical limb ischaemia (CLI). It was focused on exploring the clinical background and prior statin and renin-angiotensin system (RAS)-acting agents pharmacotherapy related to the therapeutic efficacy of BMCs treatment. METHODS In the present study, we reviewed thirty-three patients (mean age 64.9 ± 10 years; 31 males) with advanced CLI after failed or impossible revascularisation, who were treated with 40 mL of autologous BMCs by local intramuscular application. Patients with limb salvage and wound healing (N = 22) were considered as responders to BMCs therapy, and patients with limb salvage and complete ischemic wound healing (N = 13) were defined as super-responders. Logistic regression models were used to screen and identify the prognostic factors, and a receiver operating characteristics (ROC) curve, a linear regression, and a survival curve were drawn to determine the predictive accuracy, the correlation between the candidate predictors, and the risk of major amputation. RESULTS Based on the univariate regression analysis, baseline C-reactive protein (CRP) and transcutaneous oxygen pressure (TcPO2) values were identified as prognostic factors of the responders, while CRP value, ankle-brachial index (ABI), and bone marrow-derived mononuclear cells (BM-MNCs) concentration were identified as prognostic factors of the super-responders. An area under the ROC curve of 0.768 indicated good discrimination for CRP > 8.1 mg/L before transplantation as a predictive factor for negative clinical response. Linear regression analysis revealed a significant dependence between the levels of baseline CRP and the concentration of BM-MNCs in transplanted bone marrow. Patients taking atorvastatin before BMCs treatment (N = 22) had significantly improved TcPO2 and reduced pain scale after BMCs transplant, compared to the non-atorvastatin group. Statin treatment was associated with reduced risk for major amputation. However, the difference was not statistically significant. Statin use was also associated with a significantly higher concentration of BM-MNCs in the transplanted bone marrow compared to patients without statin treatment. Patients treated with RAS-acting agents (N = 20) had significantly reduced pain scale after BMCs transplant, compared to the non-RAS-acting agents group. Similar results, reduced pain scale and improved TcPO2, were achieved in patients treated with atorvastatin and RAS-acting agents (N = 17) before BMCs treatment. Results of the Spearman correlation showed a significant positive correlation between CLI regression, responders, and previous therapy before BMCs transplant with RAS-acting agents alone or with atorvastatin. CONCLUSIONS CRP and TcPO2 were prognostic factors of the responders, while CRP value, ABI, and BM-MNCs concentration were identified as predictive factors of the super-responders. Atorvastatin treatment was associated with a significantly increased concentration of BM-MNCs in bone marrow concentrate and higher TcPO2 and lower pain scale after BMCs treatment in CLI patients. Similarly, reduced pain scales and improved TcPO2 were achieved in patients treated with atorvastatin and RAS-acting agents before BMCs treatment. Positive correlations between responders and previous treatment before BMCs transplant with RAS-acting agents alone or with atorvastatin were significant.
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Affiliation(s)
- Jan Kyselovic
- 5th Department of Internal Medicine, Faculty of Medicine, Comenius University Bratislava, Špitálska 24, 81372 Bratislava, Slovakia; (J.K.)
- Department of Pharmacology and Toxicology, University of Veterinary Medicine and Pharmacy, 04181 Košice, Slovakia
| | - Adriana Adamičková
- 5th Department of Internal Medicine, Faculty of Medicine, Comenius University Bratislava, Špitálska 24, 81372 Bratislava, Slovakia; (J.K.)
| | - Andrea Gažová
- Institute of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Comenius University Bratislava, Špitálska 24, 81372 Bratislava, Slovakia
| | - Simona Valášková
- International Laser Center, Slovak Centre of Scientific and Technical Information, Lamačská cesta 7315/8A, 84104 Bratislava, Slovakia
| | - Nikola Chomaničová
- International Laser Center, Slovak Centre of Scientific and Technical Information, Lamačská cesta 7315/8A, 84104 Bratislava, Slovakia
| | - Zdenko Červenák
- 5th Department of Internal Medicine, Faculty of Medicine, Comenius University Bratislava, Špitálska 24, 81372 Bratislava, Slovakia; (J.K.)
| | - Juraj Madaric
- Department of Angiology, Faculty of Medicine, Comenius University and National Institute of Cardiovascular Disease, Pod Krásnou Hôrkou 1, 83101 Bratislava, Slovakia;
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer. Diabetes Metab Res Rev 2024; 40:e3686. [PMID: 37726988 DOI: 10.1002/dmrr.3686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this guideline the IWGDF, the European Society for Vascular Surgery and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development, and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Department Internal Medicine, MUMC+, Maastricht, The Netherlands
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Meloni M, Giurato L, Andreadi A, Bellizzi E, Bellia A, Lauro D, Uccioli L. Peripheral Blood Mononuclear Cells: A New Frontier in the Management of Patients with Diabetes and No-Option Critical Limb Ischaemia. J Clin Med 2023; 12:6123. [PMID: 37834766 PMCID: PMC10573900 DOI: 10.3390/jcm12196123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 08/24/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
The current study aimed to evaluate the effectiveness of peripheral blood mononuclear cell (PB-MNC) therapy as adjuvant treatment for patients with diabetic foot ulcers (DFUs) and no-option critical limb ischaemia (NO-CLI). The study is a prospective, noncontrolled, observational study including patients with neuro-ischaemic DFUs and NO-CLI who had unsuccessful revascularization below the ankle (BTA) and persistence of foot ischaemia defined by TcPO2 values less than 30 mmHg. All patients received three cycles of PB-MNC therapy administered through a "below-the-ankle approach" in the affected foot along the wound-related artery according to the angiosome theory. The primary outcome measures were healing, major amputation, and survival after 1 year of follow-up. The secondary outcome measures were the evaluation of tissue perfusion by TcPO2 and foot pain defined by the numerical rating scale (NRS). Fifty-five patients were included. They were aged >70 years old and the majority were male and affected by type 2 diabetes with a long diabetes duration (>20 years); the majority of DFUs were infected and nearly 90% were assessed as gangrene. Overall, 69.1% of patients healed and survived, 3.6% healed and deceased, 10.9% did not heal and deceased, and 16.4% had a major amputation. At baseline and after PB-MNC therapy, the TcPO2 values were 17 ± 11 and 41 ± 12 mmHg, respectively (p < 0.0001), while the pain values (NRS) were 6.8 ± 1.7 vs. 2.8 ± 1.7, respectively (p < 0.0001). Any adverse event was recorded during the PB-MNC therapy. Adjuvant PB-MNC therapy seems to promote good outcomes in patients with NO-CLI and neuro-ischaemic DFUs.
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Affiliation(s)
- Marco Meloni
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy (E.B.); (A.B.); (D.L.)
- Division of Endocrinology and Diabetology, Department of Medical Sciences, Fondazione Policlinico “Tor Vergata”, 00133 Rome, Italy
| | - Laura Giurato
- Division of Endocrinology and Diabetes, CTO Andrea Alesini Hospital, 00145 Rome, Italy; (L.G.)
| | - Aikaterini Andreadi
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy (E.B.); (A.B.); (D.L.)
- Division of Endocrinology and Diabetology, Department of Medical Sciences, Fondazione Policlinico “Tor Vergata”, 00133 Rome, Italy
| | - Ermanno Bellizzi
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy (E.B.); (A.B.); (D.L.)
- Division of Endocrinology and Diabetology, Department of Medical Sciences, Fondazione Policlinico “Tor Vergata”, 00133 Rome, Italy
| | - Alfonso Bellia
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy (E.B.); (A.B.); (D.L.)
- Division of Endocrinology and Diabetology, Department of Medical Sciences, Fondazione Policlinico “Tor Vergata”, 00133 Rome, Italy
| | - Davide Lauro
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy (E.B.); (A.B.); (D.L.)
- Division of Endocrinology and Diabetology, Department of Medical Sciences, Fondazione Policlinico “Tor Vergata”, 00133 Rome, Italy
| | - Luigi Uccioli
- Division of Endocrinology and Diabetes, CTO Andrea Alesini Hospital, 00145 Rome, Italy; (L.G.)
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 00133 Rome, Italy
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Modugno P, Cilla S, Centritto EM, Picone V, Maiorano M, Amatuzio M, Petrilli MP, Fraticelli V, De Filippo CM, Caradonna E, Codispoti FA, Massetti M, Tshomba Y. Autologous Bone Marrow Stem Cells in Patients With Critical Limb Ischaemia not Eligible for Revascularization: A Single Centre Experience. Angiology 2023:33197231190512. [PMID: 37728082 DOI: 10.1177/00033197231190512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
We evaluated the use of autologus bone marrow stem cells transplantation in patients with critical limb ischaemia (CLI) not eligible for revascularization. Eighty consecutive patients candidate to amputation were enrolled in a single-centre retrospective study. The primary endpoint was defined as the amputation-free rate from stem cells transplantation. Secondary endpoints were the evaluation of transcutaneous oximetry and its predictive potential for probability of amputation and the evaluation of rest pain. Ankle brachial index, transcutaneous oxygen (TcpO2) and radiological imaging were performed at the enrolment and during the follow-up times. All patients were treated with auto transplant of bone marrow stem cells. Two patients died due to acute renal and acute respiratory failures. 19 patients were amputated from the thigh or leg. In total, 59 of 80 patients intended to thigh amputation saved the limb, preserving the plantar support. TcpO2 was found a predictive metric with an AUC equal to .763, and a threshold for a risk of amputation of 10% and 5% at the values ≤22.7 and ≤26.9 mmHg, respectively. Auto transplant of bone marrow stem cells seems to be a safe and an efficient option for CLI not eligible to revascularizzation.
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Affiliation(s)
- Pietro Modugno
- Vascular Surgery Unit, Gemelli Molise Hospital, Campobasso, Italy
| | - Savino Cilla
- Medical Physics Unit, Gemelli Molise Hospital, Campobasso, Italy
| | | | - Veronica Picone
- Vascular Surgery Unit, Gemelli Molise Hospital, Campobasso, Italy
| | | | | | | | | | | | - Eugenio Caradonna
- Società italiana di medicina e chirurgia rigenerativa, Caserta, Italy
| | | | - Massimo Massetti
- Cardiac Surgery Unit, Universita' Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Yamume Tshomba
- Vascular Surgery Unit, Universita' Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Fang Y, Liu H, Pan T, Fang G, Fu W, Lin J, Liu J, Dong Z. Evaluation of the lower extremity blood supply in no-option critical limb ischemia patients with stem cell transplantation by time maximum intensity projection CT perfusion: A single-centre prospective study. Vascular 2023:17085381231192852. [PMID: 37523200 DOI: 10.1177/17085381231192852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/01/2023]
Abstract
OBJECTIVES Cell therapy has had satisfactory safety and efficacy outcomes for no-option critical limb ischaemia (NO-CLI) patients. In the current study, we aimed to compare the image quality of ischaemic lower limb blood vessels shown on volumetric CT-based time maximum intensity projection CT perfusion (t-MIP CTP) versus single-phase CTA (sCTA). We also tried to quantify the blood flow of the ischaemic lower extremity based on the t-MIP technique, not only to precisely show the dynamic change in blood flow from before to after cell therapy but also to detect any relationship between this change and patient prognosis. METHODS A total of 31 patients with thromboangiitis obliterans (TAO)-induced NO-CLI who had been referred from the department of vascular surgery to undergo autologous stem cell transplantation into a single limb from January 2020 to March 2021 were prospectively enrolled in this study. Preoperative sCTA or t-MIP CTP and postoperative 1-month t-MIP CTP were performed in all patients. Clinical outcomes, including the 1-month ankle-brachial index (ABI) and 3-month CLI status, were also analysed. Image quality, including objective scores (attenuation, signal-to-noise ratio [SNR] and contrast-to-noise ratio [CNR]), subjective scores and collateral scores, was compared between preoperative sCTA and t-MIP CTP. Vascular volume was calculated as the total volume (mL) of lower limb arteries within the scanning range. All images and calculations were performed by 2 separate radiologists. Receiver operating characteristic curves were drawn to reveal the sensitivity and specificity of vascular volume and ABI in predicting prognosis. RESULTS Both sCTA and t-MIP CTP images exhibited good quality for diagnosis. t-MIP CTP images showed significantly higher attenuation, SNR and CNR in all arterial segments (popliteal artery, anterior tibial artery, posterior tibial artery and peroneal artery). In subjective and collateral score evaluations, t-MIP CTP images were also significantly better than sCTA images (both p < .05). At 1 month after transplantation, both vascular volume and ABI showed significant improvement (both p < .01). At 3 months after transplantation, 38.71% of patients (12/31) achieved CLI relief (Rutherford class < 4). Through the receiver operating characteristic (ROC) curve, the 1-month vascular volume increase ratio showed better ability to predict the 3-month prognosis (radiologist 1: AUC, 0.757; sensitivity, 0.750; specificity, 0.840; radiologist 2: AUC, 0.803; sensitivity, 0.500; specificity, 1.000) than the 1-month ABI increase ratio (AUC, 0.607; sensitivity, 0.230; specificity, 0.820) or 1-month ABI (AUC, 0.410; sensitivity, 0.080; specificity, 0.580). CONCLUSION t-MIP CTP showed significantly higher-quality images of ischaemic limb vascularity than sCTA. t-MIP CTP can reveal the anatomical information of collaterals more accurately, which is of great importance for NO-CLI patients undergoing cell transplantation. The 1-month vascular volume increase ratio can predict the 3-month prognosis more precisely on this basis.
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Affiliation(s)
- Yuan Fang
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Hao Liu
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Tianyue Pan
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Gang Fang
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Weiguo Fu
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
| | - Jiang Lin
- Departments of Medical Imaging of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junzhen Liu
- Departments of Medical Imaging of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhihui Dong
- Departments of Vascular Surgery of Zhongshan Hospital, Fudan University, Shanghai, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
- Institute of Vascular Surgery, Fudan University, Shanghai, China
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Rodway AD, Harris J, Hanna L, Allan C, Casal FP, Giltinan C, Dehghan-Nayeri A, Santos A, Whyte MB, Ntagiantas N, Walton I, Brown R, Skene SS, Pankhania A, Field BCT, Maytham GD, Heiss C. Understanding the Impact of COVID-19 on Angioplasty Service and Outcome of Patients Treated for Chronic Limb-Threatening Ischaemia: A Single-Centre Retrospective Cohort Study. Biomedicines 2023; 11:2034. [PMID: 37509673 PMCID: PMC10377405 DOI: 10.3390/biomedicines11072034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 05/31/2023] [Revised: 07/09/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
We evaluated the impact of COVID-19 restriction on the angioplasty service and outcome of chronic limb-threatening ischaemia (CLTI) patients undergoing lower-limb angioplasty in a UK secondary care setting. Consecutive patients were analysed retrospectively. Pre-COVID-19 (08/2018-02/2020), 106 CLTI patients (91% Fontaine 4; 60% diabetes mellitus) and during COVID-19 (03/2020-07/2021) 94 patients were treated (86% Fontaine 4; 66% diabetes mellitus). While the average monthly number of patients treated did not change, the proportion of day cases significantly increased (53% to 80%), and hospitalised patients decreased. Patients treated in ≤14/5 days after referral significantly increased to 64/63%. Kaplan-Meier survival analysis (30-day/1-year) showed that neither wound healing nor mortality were significantly changed during COVID-19. In day cases, 1-year but not 30-day major amputations significantly increased, and clinically driven target-lesion revascularisation decreased during COVID-19. One-year mortality was significantly worse in hospitalised compared to day cases (14% vs. 43%) at similar wound healing rates (83% vs. 84%). The most frequent known cause of death was infectious disease (64%), while cardiovascular (21%) was less frequent. Despite COVID-19 restrictions, a safe and effective angioplasty service was maintained while shortening waiting times. Very high mortality rates in hospitalised patients may indicate that CLTI patients need to be referred and treated more aggressively earlier.
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Affiliation(s)
- Alexander D Rodway
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Vascular Surgery, University Hospital Sussex NHS Trust, Brighton BN2 5BE, UK
| | - Jenny Harris
- Department of Adult Nursing, School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Lydia Hanna
- Department of Vascular Surgery, Imperial College Healthcare NHS Trust, London SW7 2BX, UK
| | - Charlotte Allan
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
| | - Felipe Pazos Casal
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
| | - Ciara Giltinan
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Ali Dehghan-Nayeri
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Andre Santos
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Martin B Whyte
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Nikolaos Ntagiantas
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- St. George's Vascular Institute, St. George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Ivan Walton
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- St. George's Vascular Institute, St. George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Richard Brown
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
| | - Simon S Skene
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Ajay Pankhania
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
| | - Benjamin C T Field
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
| | - Gary D Maytham
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- St. George's Vascular Institute, St. George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Christian Heiss
- Department of Vascular Medicine, Surrey and Sussex Healthcare NHS Trust, Redhill RH1 5RH, UK
- Department of Clinical and Experimental Medicine, School of Biosciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7XH, UK
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Gormley S, Hart O, French S, O'Shea C, Khashram M. The use of fetal bovine acellular dermal matrix in severe diabetic foot ulceration and threatened limbs with tissue loss the use of FBADM as an adjunct for complex wounds. Vascular 2022:17085381221141115. [PMID: 36415107 DOI: 10.1177/17085381221141115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVES Foot ulceration associated with diabetic foot disease (DFD) and chronic limb-threatening ischaemia (CLTI) presents a complex clinical challenge and failure to heal the wound imposes a significant risk of major limb amputation (MLA). In attempt to accelerate wound healing rates and decrease MLA, tissue engineering research into bio-engineered scaffolds and skin substitutes has become a growing area of interest. Advanced wound therapies such as fetal bovine acellular dermal matrix (FBADM) may have success in the treatment of difficult to heal chronic foot ulcers. The FBADM traps and binds the patients' own epithelial cells to rebuild the dermis layer of the skin. Previous studies have suggested that wounds treated with FBADM had a faster healing rate than wounds managed with conventional dressings. However, these studies excluded foot wounds with chronic exposed bone or tendon, active infection, gangrene, or osteomyelitis and patients with uncontrolled blood glucose levels were excluded. The aim of this study was to assess the efficacy of FBADM for patients admitted to hospital acutely with severe foot ulceration secondary to DFD and CLTI. METHODS Between February 2020 and December 2021, inpatients admitted acutely at a single tertiary centre with a severe non-healing foot ulcer and had a wound suitable for application of a FBADM after primary debridement were included in the study. A severe non-healing foot wound was defined as a Society for Vascular Surgery Wound, Ischaemia, and foot Infection (WIfI) stage of 3 or 4. Participants were prospectively followed up at regular intervals at a multidisciplinary high-risk diabetic foot clinic until June 2022. The primary endpoint was time to wound closure. The secondary endpoints were number of applications of FBADM, readmission rate and amputation-free survival. RESULTS There were 22 patients included in the study with a median age of 71 (50-87) years and 15 were male. Five patients had a WIfI stage of 3 and 17 had a WIfI score of 4. Overall, 14 patients required revascularisation procedures (6 open surgery,8 endovascular intervention). A total of 18 patients achieved complete wound healing with a median time to wound healing of 178 (28-397) days. Two patients underwent a MLA and two patients died prior to complete wound healing. The median length of stay was 16.5 (5-115) days, and 4 patients were readmitted to hospital within 12 months. CONCLUSION FBADM may be a useful adjunct in the acute setting of complex DFD and CLTI ulceration to assist with wound healing. Future comparative prospective studies are required to further validate these preliminary findings.
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Affiliation(s)
- Sinead Gormley
- Department of Vascular & Endovascular Surgery, 3718Waikato Hospital, Hamilton, New Zealand
- Faculty of Medical & Health Sciences, 62710The University of Auckland, Auckland, New Zealand
| | - Odette Hart
- Department of Vascular & Endovascular Surgery, 3718Waikato Hospital, Hamilton, New Zealand
- Department of Surgery, 62710The University of Auckland, Auckland, New Zealand
| | - Stephen French
- Department of Vascular & Endovascular Surgery, 3718Waikato Hospital, Hamilton, New Zealand
| | - Claire O'Shea
- Department of Surgery, 62710The University of Auckland, Auckland, New Zealand
| | - Manar Khashram
- Department of Vascular & Endovascular Surgery, 3718Waikato Hospital, Hamilton, New Zealand
- Department of Surgery, 62710The University of Auckland, Auckland, New Zealand
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Umur L, Selçuk I. Prosthetic vascular graft management in above-knee amputations. Cardiovasc J Afr 2022; 33:313-316. [PMID: 35211716 PMCID: PMC10031853 DOI: 10.5830/cvja-2022-012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 02/09/2022] [Indexed: 10/08/2023] Open
Abstract
OBJECTIVE Critical limb ischaemia (CLI) is the most severe state of peripheral arterial disease and is one of the major causes of lower-limb amputations. One of the treatment choices is prosthetic vascular grafts. Despite treatment, CLI may lead to amputation owing to infection or progressive ischaemia. The aim of this study was to show that multidisciplinary planning and surgery for CLI patients with prosthetic grafts decreased the duration of hospital stay, costs, risk of infection and ascending conversion of the amputation level. METHODS Forty-two above-knee amputation patients with grafts were retrospectively evaluated. Group A patients (n = 24) had partial excision and group B patients ( n = 18) total excision with or without saphenous patch-plasty, according to the patency of the deep femoral artery. Growth in wound culture, antibiotic therapy duration, conversion to hip disarticulation and hospitalisation periods were compared. RESULTS Differences in growth of wound culture (p = 0.007), antibiotic duration (p = 0.003), hip disarticulation (p = 0.029) and duration of hospital stay (p = 0.0001) between the two groups were found to be statistically significant (p < 0.05). CONCLUSIONS Management of CLI patients is a complex process, and a multidisciplinary approach is key to avoiding undesirable outcomes. Meticulous planning, including excision of the total graft, while ensuring the vascular supply, is essential.
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Affiliation(s)
- Levent Umur
- Department of Orthopaedics and Traumatology, Acibadem Kadikoy Hospital, Istanbul, Turkey.
| | - Ismail Selçuk
- Department of Cardiovascular Surgery, Sultan Abdulhamid Han Teaching and Research Hospital, Istanbul, Turkey
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9
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Yang Q, Li L, Zha Y, Yan Y, Xing D, Liu H, Yang L, Peng L, Zhang Y. Microvascular Permeability and Texture Analysis of the Skeletal Muscle of Diabetic Rabbits With Critical Limb Ischaemia Based on DCE-MRI. Front Endocrinol (Lausanne) 2022; 13:783163. [PMID: 35250854 PMCID: PMC8894257 DOI: 10.3389/fendo.2022.783163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/04/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We evaluated skeletal muscle vascular permeability in diabetic rabbits with critical limb ischaemia using quantitative dynamic contrast agent-enhanced (DCE) magnetic resonance imaging (MRI) and explored the feasibility of using DCE-MRI Ktrans-based texture analysis for assessing early slight ischaemia-related skeletal muscle structural changes. METHOD Twenty-four male New Zealand white rabbits (2.7 ± 0.3 kg; n = 12 each in sham-operated and experimental groups) underwent axial MRI of the vastus lateralis muscle at 1, 2, and 3 weeks after alloxan injection. Between-group and intra-group postoperative permeability and texture parameters were compared. Texture features of experimental groups in the third week were modelled by receiver operating characteristic (ROC) curve analysis. Correlations of permeability and of statistical texture parameters with peripheral blood endothelial progenitor cells (EPCs) and microvascular density (MVD) were analysed. RESULTS In the experimental group, the transfer constant (Ktrans) was statistically significant at all time-points (F = 5.800, P = 0.009). Their vastus lateralis muscle Ktrans was significantly lower in the third than in the first week (P = 0.018) and correlated positively with peripheral blood EPCs in the experimental group [r = 0.598, (95% CI: 0.256, 0.807)]. The rate constant was negatively associated with vastus lateralis muscle MVD [r = -0.410, (95% CI: -0.698, -0.008)]. The area under the ROC curve of texture parameters based on Ktrans in ischaemic limbs was 0.882. CONCLUSIONS Quantitative DCE-MRI parameters could evaluate microvascular permeability of ischaemic limb skeletal muscle, and texture analysis based on DCE-MRI Ktrans allowed evaluation of early slight skeletal muscle structural changes.
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Affiliation(s)
- Qi Yang
- Department of Radiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Liang Li
- Department of Radiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yunfei Zha
- Department of Radiology, Renmin Hospital of Wuhan University, Wuhan, China
- *Correspondence: Yunfei Zha,
| | - Yuchen Yan
- Department of Radiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Dong Xing
- Department of Radiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Huan Liu
- Advanced Application Team, GE Healthcare, Shanghai, China
| | - Liu Yang
- Department of Radiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Lin Peng
- Department of Radiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yubiao Zhang
- Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan, China
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Herron C, Hastings CL, Herron-Rice C, Kelly HM, O'Dwyer J, Duffy GP. A Thermoresponsive Chitosan/β-Glycerophosphate Hydrogel for Minimally Invasive Treatment of Critical Limb Ischaemia. Polymers (Basel) 2021; 13:3568. [PMID: 34685327 DOI: 10.3390/polym13203568] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 09/21/2021] [Revised: 10/12/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022] Open
Abstract
A reduction in blood supply to any limb causes ischaemia, pain and morbidity. Critical limb ischaemia is the most serious presentation of peripheral vascular disease. One in five patients with critical limb ischaemia will die within six months of diagnosis and one in three will require amputation in this time. Improving blood flow to the limb, via the administration of angiogenic agents, could relieve pain and avoid amputation. Herein, chitosan is combined with β-glycerophosphate to form a thermoresponsive formulation (chitosan/β-GP) that will flow through a syringe and needle at room temperature but will form a gel at body temperature. The chitosan/β-GP hydrogel, with or without the angiogenic molecule desferrioxamine (DFO), was injected into the mouse hind limb, following vessel ligation, to test the ability of the formulations to induce angiogenesis. The effects of the formulations were measured using laser Doppler imaging to determine limb perfusion and CD31 staining to quantify the number of blood vessels. Twenty-eight days following induction of ischaemia, the chitosan/β-GP and chitosan/β-GP + 100 µM DFO formulations had significantly (p < 0.001 and p < 0.05, respectively) improved blood flow in the ischaemic limb compared with an untreated control. Chitosan/β-GP increased vessel number by 1.7-fold in the thigh of the ischaemic limb compared with an untreated control, while chitosan/β-GP + 100 µM DFO increased vessel number 1.8-fold. Chitosan/β-GP represents a potential minimally invasive treatment for critical limb ischaemia.
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11
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Zenunaj G, Lamberti N, Manfredini F, Traina L, Acciarri P, Bisogno F, Scian S, Serra R, Abatangelo G, Gasbarro V. Infrared Thermography as a Diagnostic Tool for the Assessment of Patients with Symptomatic Peripheral Arterial Disease Undergoing Infrafemoral Endovascular Revascularisations. Diagnostics (Basel) 2021; 11:diagnostics11091701. [PMID: 34574042 PMCID: PMC8469591 DOI: 10.3390/diagnostics11091701] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/12/2021] [Accepted: 09/13/2021] [Indexed: 12/24/2022] Open
Abstract
Aim: The aim of this study was to evaluate the utility and reliability of temperature foot changes measured by infrared thermography (IRT) for the evaluation of patients with atherosclerotic peripheral arterial disease (PAD) before and after endovascular revascularisation. Methods: This is an observational prospective study carried out on symptomatic PAD patients. Evaluations consisted of a clinical examination, duplex scan with ankle–brachial index calculation (ABI) and IRT measurements with infrared camera FLIR-ONE connected to a smartphone with android technology. Locations on the foot sampled with IRT were the anterior tibial, pedal, posterior and arcuate arteries. Results obtained with IRT on the symptomatic foot were compared to the contralateral foot and with the ABI values obtained bilaterally before and 24 h after revascularisation. Results: Within one year, 40 patients were enrolled, among whom 87,5% suffered from critical limb ischaemia. In three patients, it was impossible to obtain ABI measurements because of ulcerations on the limb. Skin temperature changes obtained by IRT between the symptomatic limb and the contralateral limb had a mean difference of 1.7 °C (range: 1.1–2.2 °C), p < 0.001. There was a positive correlation between ABI and temperature values of the limb needed for treatment before revascularisation (p = 0.025; r = 0.36) and after revascularisation (p = 0.024, r = 0.31). The technical success rate was 100% in all cases, achieving a significant increase in temperature at all points of the foot analysed, with a median change of 2 °C (p < 0.001). Conclusion: IRT is a safe, reliable and simple application. It could be a valuable tool for the assessment of the clinical presentation and severity of foot blood perfusion in symptomatic PAD patients and the evaluation of the technical success of endovascular revascularisation. IRT might have a role in follow-up of revascularisation procedures.
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Affiliation(s)
- Gladiol Zenunaj
- Department of Surgery, Unit of Vascular and Endovascular Surgery, University Hospital Arcispedale Sant’Anna of Ferrara, Via Aldo Moro 8, Cona, 44100 Ferrara, Italy; (L.T.); (P.A.); (V.G.)
- Correspondence:
| | - Nicola Lamberti
- Department of Neuroscience and Rehabilitation, Section of Sport Sciences, University of Ferrara, Via Ludovico Ariosto, 44121 Ferrara, Italy; (N.L.); (F.M.); (F.B.); (S.S.); (G.A.)
| | - Fabio Manfredini
- Department of Neuroscience and Rehabilitation, Section of Sport Sciences, University of Ferrara, Via Ludovico Ariosto, 44121 Ferrara, Italy; (N.L.); (F.M.); (F.B.); (S.S.); (G.A.)
| | - Luca Traina
- Department of Surgery, Unit of Vascular and Endovascular Surgery, University Hospital Arcispedale Sant’Anna of Ferrara, Via Aldo Moro 8, Cona, 44100 Ferrara, Italy; (L.T.); (P.A.); (V.G.)
| | - Pierfilippo Acciarri
- Department of Surgery, Unit of Vascular and Endovascular Surgery, University Hospital Arcispedale Sant’Anna of Ferrara, Via Aldo Moro 8, Cona, 44100 Ferrara, Italy; (L.T.); (P.A.); (V.G.)
| | - Francesca Bisogno
- Department of Neuroscience and Rehabilitation, Section of Sport Sciences, University of Ferrara, Via Ludovico Ariosto, 44121 Ferrara, Italy; (N.L.); (F.M.); (F.B.); (S.S.); (G.A.)
| | - Sabrina Scian
- Department of Neuroscience and Rehabilitation, Section of Sport Sciences, University of Ferrara, Via Ludovico Ariosto, 44121 Ferrara, Italy; (N.L.); (F.M.); (F.B.); (S.S.); (G.A.)
| | - Raffaele Serra
- Department of Medical and Surgical Sciences, Università Magna Graecia di, 88100 Catanzaro, Italy;
| | - Giulio Abatangelo
- Department of Neuroscience and Rehabilitation, Section of Sport Sciences, University of Ferrara, Via Ludovico Ariosto, 44121 Ferrara, Italy; (N.L.); (F.M.); (F.B.); (S.S.); (G.A.)
| | - Vincenzo Gasbarro
- Department of Surgery, Unit of Vascular and Endovascular Surgery, University Hospital Arcispedale Sant’Anna of Ferrara, Via Aldo Moro 8, Cona, 44100 Ferrara, Italy; (L.T.); (P.A.); (V.G.)
- Department of Neuroscience and Rehabilitation, Section of Sport Sciences, University of Ferrara, Via Ludovico Ariosto, 44121 Ferrara, Italy; (N.L.); (F.M.); (F.B.); (S.S.); (G.A.)
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Meloni M, Morosetti D, Giurato L, Stefanini M, Loreni G, Doddi M, Panunzi A, Bellia A, Gandini R, Brocco E, Lazaro-Martinez JL, Lauro D, Uccioli L. Foot Revascularization Avoids Major Amputation in Persons with Diabetes and Ischaemic Foot Ulcers. J Clin Med 2021; 10:3977. [PMID: 34501432 DOI: 10.3390/jcm10173977] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 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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13
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Sermsathanasawadi N, Pruekprasert K, Chruewkamlow N, Kittisares K, Warinpong T, Chinsakchai K, Wongwanit C, Ruangsetakit C, Mutirangura P. Peripheral blood mononuclear cell transplantation to treat no-option critical limb ischaemia: effectiveness and safety. J Wound Care 2021; 30:562-567. [PMID: 34256601 DOI: 10.12968/jowc.2021.30.7.562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Local intramuscular transplantation of granulocyte colony-stimulating factor (G-CSF)-mobilised peripheral blood mononuclear cells (PB-MNC) has been shown to be effective for treating patients with no-option critical limb ischaemia (CLI) who are not considered suitable to undergo surgical bypass or percutaneous transluminal angioplasty. The aim of this study was to investigate the effectiveness and safety of PB-MNCs as a treatment for no-option CLI patients. METHOD This prospective cohort study was conducted between April 2013 and December 2017. Patients with no-option CLI were treated with G-CSF 5-10 µg/kg/day for 3 days. PB-MNCs (7.1±2.2×1010) with CD34+ cells (2.1±1.2×108) were collected by blood cell separator and then injected into the calf or thigh of ischaemic limbs. Ankle-brachial index, toe-brachial index and transcutaneous oxygen tension were recorded at 1 and 3 months after injection. The amputation rate and the wound healing rate were also recorded. RESULTS Eight patients took part in the study. Two patients experienced rest pain relief 1 month after PB-MNC therapy. Five patients had healed ulcer at 6 months after PB-MNC therapy. Limb ischaemia did not improve after PB-MNC therapy in one patient. Below-knee amputation was performed in that patient due to extension of gangrene. Two patients required reinjection of PB-MNCs because of recurrence of ischaemic ulcer. The limb salvage rate after 1 year was 87.5%. CONCLUSION Local intramuscular transplantation of G-CSF-mobilised PB-MNCs might be a safe and effective treatment for no-option CLI patients.
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Affiliation(s)
- Nuttawut Sermsathanasawadi
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kanin Pruekprasert
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Nuttapol Chruewkamlow
- Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Kulvara Kittisares
- Department of Transfusion Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thanatphak Warinpong
- Department of Transfusion Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Khamin Chinsakchai
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chumpol Wongwanit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanean Ruangsetakit
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pramook Mutirangura
- Division of Vascular Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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14
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Maeda T, Yamamoto Y, Murao N, Hayashi T, Kimura C, Matsui S, Saito T, Matsui H, Osawa M, Funayama E. Maggot debridement therapy in critical limb ischaemia: a case study. J Wound Care 2021; 29:S28-S32. [PMID: 33320762 DOI: 10.12968/jowc.2020.29.sup12.s28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE In critical limb ischaemia (CLI), first-line therapy is revascularisation, but alternative treatment options are needed in certain cases. Maggot debridement therapy (MDT) is historically considered to be contraindicated in ischaemic ulcers. Wound care in patients with CLI is becoming increasingly diverse with the development of novel revascularisation strategies; therefore, CLI now needs to be reconsidered as an indication for MDT. METHOD We retrospectively reviewed five legs with CLI (five male, one female) treated with MDT between January 2013 and December 2017. Changes in skin perfusion pressure (SPP) around the ulcer before and after MDT were evaluated. One or two cycles of MDT were performed (eight in total). We also evaluated the proportion of necrotic tissue in the ulcer and the presence of exposed necrotic bone. The proportion of necrotic tissue in the ulcer was classified as NT 1+ (<25%), NT 2+ (25-50%), NT 3+ (50-75%) or NT 4+ (>75%). RESULTS When the proportion of necrotic tissue was >50%, with no exposed necrotic bone in the wound, an increase in SPP was observed after five (62.5%) of eight cycles of MDT. And with a proportion of necrotic tissue of <25% and/or exposed necrotic bone in the wound, a decrease in SPP was observed after three (37.5%) of eight cycles. Wound healing was accelerated in the presence of increased SPP. CONCLUSION Effective MDT with increased SPP requires an ulcerative state of necrotic tissue grade > NT 3+, with no exposed necrotic bone.
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Affiliation(s)
- Taku Maeda
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Yuhei Yamamoto
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Naoki Murao
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Toshihiko Hayashi
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Chu Kimura
- Department of Plastic and Reconstructive Surgery, Hakodate General Central Hospital, Hokkaido, Japan
| | - Suguru Matsui
- Center of Limb Salvage and Wound Care, Souen Central Hospital, Sapporo, Hokkaido, Japan
| | - Tatsuya Saito
- Center of Limb Salvage and Wound Care, Souen Central Hospital, Sapporo, Hokkaido, Japan
| | - Hotaka Matsui
- Center of Limb Salvage and Wound Care, Souen Central Hospital, Sapporo, Hokkaido, Japan
| | - Masayuki Osawa
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
| | - Emi Funayama
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Japan
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Cimaglia P, Dalla Paola L, Carone A, Scavone G, Manfrini M, Brogneri S, Tenti E, Pavasini R, Bernucci D, Passarini G, Vitali F, Gaudenzi E, Ferrari R, Campo G. High-Sensitivity Cardiac Troponin Predicts Major Cardiovascular Events in Diabetic Patients With Critical Limb Ischemia and Foot Lesions. Front Cardiovasc Med 2021; 8:595701. [PMID: 34124184 PMCID: PMC8192711 DOI: 10.3389/fcvm.2021.595701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 04/26/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Diabetic patients with critical limb ischemia (CLI) and foot lesions show a poor prognosis. Optimal risk stratification to guide tailored intervention is still uncertain. The aim of the present study was to assess the prognostic role of high-sensitivity cardiac troponin T (hs-TnT) in such a high-risk population. Methods and Results: Clinical, laboratory, and interventional data, as well as the SPINACH score, were collected. Hs-TnT was measured at hospital admission. All patients were followed up for at least 1 year. The primary endpoint was the cumulative occurrence of major cardiovascular events (MACEs, all-cause death, myocardial infarction, or stroke). The secondary endpoint was all-cause mortality. Overall, 618 patients were included and followed for a median of 981 (557-1,325) days. Diagnosis of coronary artery disease (CAD) was established in 270 (43.7%) patients. Median hs-TnT at admission was 31 (20-59) ng/L, with 525 (85%) patients over the upper reference limit. Hs-TnT values were significantly higher in patients with established CAD (39 vs. 29 ng/L, p < 0.01). Hs-TnT was an independent predictor of MACE (HR 2.440, 95% CI 1.706-3.489, p < 0.001). The best cut-offs were 40 ng/L (AUC 0.711) for patients with established CAD and 25 ng/L (AUC 0.725) for those without. Hs-TnT emerged also as an independent predictor of all-cause mortality. The addition of hs-TnT improved prognostic value of the SPINACH score. Conclusions: Hs-TnT is a powerful biomarker for prognostic stratification of diabetic CLI patients with foot lesions. This is confirmed independently to CAD diagnosis and permits the identification of higher risk patients requiring tailored intervention.
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Affiliation(s)
- Paolo Cimaglia
- Cardiovascular Department, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Luca Dalla Paola
- Cardiovascular Department, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Anna Carone
- Cardiovascular Department, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Giuseppe Scavone
- Cardiovascular Department, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Marco Manfrini
- Cardiovascular Department, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Simona Brogneri
- Cardiovascular Department, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Elena Tenti
- Cardiovascular Department, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Rita Pavasini
- Cardiovascular Center, University of Ferrara, Ferrara, Italy
| | - Davide Bernucci
- Cardiovascular Center, University of Ferrara, Ferrara, Italy
| | | | | | | | - Roberto Ferrari
- Cardiovascular Department, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy.,Cardiovascular Center, University of Ferrara, Ferrara, Italy
| | - Gianluca Campo
- Cardiovascular Department, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy.,Cardiovascular Center, University of Ferrara, Ferrara, Italy
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16
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Machin M, Younan HC, Guéroult AM, Onida S, Shalhoub J, Davies AH. Systematic review of inframalleolar endovascular interventions and rates of limb salvage, wound healing, restenosis, rest pain, reintervention and complications. Vascular 2021; 30:105-114. [PMID: 33789557 PMCID: PMC8862126 DOI: 10.1177/17085381211004246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Peripheral artery disease is estimated to affect 237 million individuals worldwide. Critical limb ischaemia, also known as chronic limb threatening ischaemia is a consequence of the progression of peripheral artery disease which occurs in ∼21% of patients over a five-year period. The aim of this systematic review is to assess the use of additional below-the-ankle angioplasty in comparison to the use of above-the-ankle angioplasty alone, and the subsequent rates of amputation, wound healing, restenosis, rest pain, reintervention and complications. Methods This systematic review was undertaken in accordance with PRISMA guidelines following a registered protocol (CRD42019154893). Online databases were searched using a search strategy of 20 keywords. Included articles reported the outcome for inframalleolar (pedal artery, pedal arch, plantar arteries) angioplasty with additional proximal angioplasty in comparison to proximal angioplasty alone. GRADE assessment was applied to assess the quality of the evidence. Results After screening 1089 articles, 10 articles met the inclusion criteria. Comparative performance assessment of below-the-ankle with above-the-ankle versus above-the-ankle angioplasty alone was undertaken in 3 articles, with the remaining 7 articles reporting outcomes of below-the-ankle with above-the-ankle angioplasty with no distinct comparator group. Significant decrease in major lower limb amputation at the last follow-up in the below-the-ankle group when compared with the above-the-ankle angioplasty alone group was observed in a single study (3.45% vs. 14.9%, p < 0.05). Improved wound healing rate at follow-up in the below-the-ankle group versus above-the-ankle angioplasty alone group was also reported in a single study (59.3% vs. 38.1%, p < 0.05). Subsequent rate of amputation after below-the-ankle angioplasty has been estimated as 23.5%. Conclusion To date, there is a lack of studies assessing inframalleolar interventions and their use in improving limb salvage, wound healing and symptomatology. Prospective RCTs should be undertaken with adequate participant numbers to be sufficiently powered and report clinically important end-points.
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Affiliation(s)
- M Machin
- Academic section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
- M Machin, 4 East, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
| | - HC Younan
- Department of Public Health, Imperial College London, London, UK
| | - AM Guéroult
- Academic section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - S Onida
- Academic section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - J Shalhoub
- Academic section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - AH Davies
- Academic section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
- AH Davies, 4 East, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
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17
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Abstract
OBJECTIVES Revascularization according to the angiosome concept is of proven importance for limb salvage in chronic limb threatening ischaemia but it is not always practicable. Bifurcated bypasses could be considered as an option when an endovascular approach is not feasible or has already failed and a single bypass would not allow direct revascularization of the ischaemic area. Bifurcated bypasses are characterized by landing on two different arteries, the main artery (in direct continuity with the foot vessels) and the secondary one (perfusing the angiosome district). The aim of this study is to evaluate the safety and effectiveness of bifurcated bypass in chronic limb threatening ischaemia. METHODS Thirty-five patients were consecutively treated with a bifurcated bypass for chronic limb threatening ischaemia from January 2014 to December 2019 in a single vascular surgery centre. Data from clinical records and operative registers were collected prospectively in an electronic database and retrospectively analysed. Primary and primary assisted bypass patency, amputation-free survival, morbidity and mortality rates at 12 and 24 months were analysed. RESULTS Mean follow-up period was 25.1 months (range 2-72 months). Thirty-six bifurcated bypasses were performed on 35 patients (age 75.3 ± 7.2 years; 69.4% were male). According to Wound, Ischemia, foot Infection classification 22.2% belonged to stage 3 and 77.8% to stage 4 and the mean Rutherford's class was 5.1 ± 0.7. Immediate technical success was 100%. Early mortality and morbidity rates were respectively 5.5%, and 33.3%; foot surgery was performed in 50% of cases with wound healing in all patients. Primary patency and primary assisted bypass patency were 96.7% and 100% at 6 months; 85.2% and 92% at 12 months, 59.9% and 73.4% at 24 months, respectively. Amputation-free survival at 12 and 24 months was, respectively, 95.6% and 78.8%. Overall survival rates at 12 and 24 months were respectively 94.4% and 91.6%. CONCLUSIONS Bifurcates bypass can provide good results in patients with chronic limb threatening ischaemia without endovascular option, especially in diabetic ones. Bifurcated bypass is a complex surgical solution, both to be planned and performed, and it is quite invasive for frail patients that should be accurately selected.
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Affiliation(s)
- Daniele Adami
- Vascular Surgery Unit, Cardio Thoracic and Vascular Department, Pisa University Hospital, Pisa, Italy
| | - Michele Marconi
- Vascular Surgery Unit, Cardio Thoracic and Vascular Department, Pisa University Hospital, Pisa, Italy
| | - Alberto Piaggesi
- Diabetic Foot Section, Endocrinology and Metabolism Department, Pisa University Hospital, Pisa, Italy
| | - Davide M Mocellin
- Vascular Surgery Unit, Cardio Thoracic and Vascular Department, Pisa University Hospital, Pisa, Italy
| | - Raffaella N Berchiolli
- Vascular Surgery Unit, Cardio Thoracic and Vascular Department, Pisa University Hospital, Pisa, Italy
| | - Mauro Ferrari
- Vascular Surgery Unit, Cardio Thoracic and Vascular Department, Pisa University Hospital, Pisa, Italy
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18
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Rodway A, Stafford M, Wilding S, Ntagiantas N, Patsiogiannis V, Allan C, Field B, Clark J, Casal FP, Pankhania A, Loosemore T, Heiss C. Day case angioplasty in a secondary care setting - initial experience. VASA 2021; 50:202-208. [PMID: 33599142 DOI: 10.1024/0301-1526/a000942] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Peripheral artery disease presents an increasing healthcare burden worldwide. Day-case angioplasty in a secondary care setting can be a safe and effective means of meeting the growing demand for lower limb revascularisation. We evaluated the safety and efficacy of a day-case-based angioplasty service in a UK district general hospital. Patients and methods: Consecutive patients undergoing endovascular revascularisation between August 2018-February 2020 were analysed retrospectively. All patients were discussed at a multi-disciplinary (diabetic foot) team meeting following a day case algorithm. Patient and procedural characteristics, technical success, peri-procedural complications, and 30-day outcome of day-case angioplasties were compared with those requiring overnight stay or were hospitalized. Results: Fifty-seven percent of 138 patients were diabetic, mean age 75 ± 12 years, 95% had critical limb ischaemia (Fontaine III 12%, IV 83%), and baseline ankle brachial pressure index [ABPI] 0.40 ± 0.30. Sixty-three patients (45%) were treated as planned day cases, 21 (15%) required overnight admission for social indications. Fifteen (11%) were planned admissions with the need for sequential debridement procedures, and 39 (28%) were already hospitalised at the time of referral to the vascular service. The overall technical success was 92% and not successful procedures mainly occurred in patients > 80 years. The ABPI increased at the initial follow-up to 0.84 ± 0.18. Fifty-three percent required treatment of > 1 level, 80% included recanalisations of chronic total occlusions, and average total lesion length was 133 ± 90 mm. Closure devices were employed in all cases. There were no major peri-procedural complications. A single minor access-site related bleeding episode (0.8%) occurred, requiring 24 h observation in hospital. While significantly more wounds had closed in out-patients, the mortality, major amputation and target lesion revascularization did not differ between groups. Conclusions: Safe and effective day-case-based angioplasty can be provided in a secondary care setting for patients with critical limb ischaemia needing complex multi-level procedures.
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Affiliation(s)
- Alexander Rodway
- Surrey and Sussex Healthcare NHS Trust, Redhill, UK.,Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Michelle Stafford
- Surrey and Sussex Healthcare NHS Trust, Redhill, UK.,First Community Health and Care, Redhill, UK
| | - Sophie Wilding
- Surrey and Sussex Healthcare NHS Trust, Redhill, UK.,Section of Clinical Medicine, Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Nikolaos Ntagiantas
- Surrey and Sussex Healthcare NHS Trust, Redhill, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Vasileios Patsiogiannis
- Surrey and Sussex Healthcare NHS Trust, Redhill, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Charlotte Allan
- Surrey and Sussex Healthcare NHS Trust, Redhill, UK.,Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Ben Field
- Surrey and Sussex Healthcare NHS Trust, Redhill, UK.,Section of Clinical Medicine, Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - James Clark
- Surrey and Sussex Healthcare NHS Trust, Redhill, UK
| | | | | | - Thomas Loosemore
- Surrey and Sussex Healthcare NHS Trust, Redhill, UK.,St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christian Heiss
- Surrey and Sussex Healthcare NHS Trust, Redhill, UK.,Section of Clinical Medicine, Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
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19
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Serra R, Bracale UM, Barbetta A, Ielapi N, Licastro N, Gallo A, Fregola S, Turchino D, Gasbarro V, Mastroroberto P, de Franciscis S. PredyCLU: A prediction system for chronic leg ulcers based on fuzzy logic; part II-Exploring the arterial side. Int Wound J 2020; 17:987-991. [PMID: 32285613 DOI: 10.1111/iwj.13360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 03/17/2020] [Accepted: 03/20/2020] [Indexed: 11/27/2022] Open
Abstract
Peripheral arterial disease (PAD) and its most severe form, critical limb ischaemia (CLI), are very common clinical conditions related to atherosclerosis and represent the major causes of morbidity, mortality, disability, and reduced quality of life (QoL), especially for the onset of ischaemic chronic leg ulcers (ICLUs) and the subsequent need of amputation in affected patients. Early identification of patients at risk of developing ICLUs may represent the best form of prevention and appropriate management. In this study, we used a Prediction System for Chronic Leg Ulcers (PredyCLU) based on fuzzy logic applied to patients with PAD. The patient population consisted of 80 patients with PAD, of which 40 patients (30 males [75%] and 10 females [25%]; mean age 66.18 years; median age 67.50 years) had ICLUs and represented the case group. Forty patients (100%) (27 males [67.50%] and 13 females [32.50%]; mean age 66.43 years; median age 66.50 years) did not have ICLUs and represented the control group. In patients of the case group, the higher was the risk calculated with the PredyCLU the more severe were the clinical manifestations recorded. In this study, the PredyCLU algorithm was retrospectively applied on a multicentre population of 80 patients with PAD. The PredyCLU algorithm provided a reliable risk score for the risk of ICLUs in patients with PAD.
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Affiliation(s)
- Raffaele Serra
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Umberto M Bracale
- Department of Public Health, University of Naples "Federico II", Naples, Italy
| | - Andrea Barbetta
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Nicola Ielapi
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy.,Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - Noemi Licastro
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Alessandro Gallo
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Salvatore Fregola
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Davide Turchino
- Department of Public Health, University of Naples "Federico II", Naples, Italy
| | - Vincenzo Gasbarro
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Pasquale Mastroroberto
- Department of Experimental and Clinical Medicine, University of Catanzaro, Catanzaro, Italy
| | - Stefano de Franciscis
- Interuniversity Center of Phlebolymphology (CIFL), International Research and Educational Program in Clinical and Experimental Biotechnology", Catanzaro, Italy.,Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
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20
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Abstract
Diabetic chronic limb-threatening ischaemia is a challenging clinical problem with patients at high risk of diabetic foot ulceration (DFU) and limb loss. Patients often remain asymptomatic even in the presence of severe pedal ischaemia until first presenting with tissue loss such as DFU or frank gangrene. Limb salvage units should have the facilities and expertise to provide multidisciplinary team-based holistic care through best medical therapy, rapid diagnosis, prompt revascularisation with endovascular or open surgical techniques and expert wound management. Endovascular revascularisation has become the first line strategy in contemporary clinical practice because of similar outcomes in wound healing and amputation rates in most patients when compared with open surgery. The primary goal is restoration of pulsatile in-line blood flow to the ankle or foot, with an angiosome-directed approach possibly achieving superior outcomes especially in diabetics with poor collaterals. A comprehensive overview of conventional endovascular techniques (such as antegrade true lumen and subintimal approaches), advanced techniques for complex disease (such as retrograde subintimal and pedal-plantar loop approaches or even deep venous arterialisation) and the various treatment options are described. Diabetic limb salvage rates can be excellent with suitable multidisciplinary expertise and care.
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Affiliation(s)
- Edward Choke
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Tjun Y Tang
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Shin C Cheng
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
| | - Jia S Tay
- Vascular Surgery, Department of General Surgery, Sengkang General Hospital, Singapore, Singapore
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21
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Gedikoglu M, Eker HE. Ultrasound-guided popliteal sciatic nerve block: an effective alternative technique to control ischaemic severe rest pain during endovascular treatment of critical limb ischaemia. Pol J Radiol 2019; 84:e537-41. [PMID: 32082452 DOI: 10.5114/pjr.2019.91271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 10/07/2019] [Accepted: 11/07/2019] [Indexed: 11/25/2022] Open
Abstract
Purpose There are challenges with pain management related to a severely ischaemic limb. Although opioid-based treatment has been the cornerstone of pain relief, the use of these drugs should be limited because of their side effects in such vulnerable patients. We evaluated the utility and efficiency of sciatic nerve block as an alternative method to relieve severe rest pain during endovascular treatment of critical limb ischaemia. Material and methods We retrospectively investigated 10 patients who received ultrasound-guided popliteal sciatic nerve block for the relief of severe rest pain during endovascular treatment of critical limb ischaemia. The degree of pain relief was evaluated by using subjective criteria, from no relief of pain (= 1) to complete relief of pain (= 4). Details of endovascular treatment, time to perform the block, amount of local anaesthetics, duration of the block, need for supplemental analgesia, patient and operator satisfaction, and complications were recorded. Results All blocks were technically successful, and all of the patients had complete resolution of the pain within five minutes. The degree of pain relief was 3 in two patients and 4 in eight patients. All patients were satisfied with the block anaesthesia, and no patient required additional analgesia during this period. Operator satisfaction was very good in all cases. Complications secondary to block did not occur in any patient. Conclusions Ultrasound-guided popliteal sciatic nerve block provides effective pain control, which results in excellent patient and operator satisfaction during endovascular treatment of critical limb ischaemia with severe rest pain.
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22
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Lim K, Lim X, Hong Q, Yong E, Chandrasekar S, Tan GWL, Lo ZJ. Use of home negative pressure wound therapy in peripheral artery disease and diabetic limb salvage. Int Wound J 2020; 17:531-539. [PMID: 31972901 DOI: 10.1111/iwj.13307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 10/24/2019] [Revised: 12/23/2019] [Accepted: 01/10/2020] [Indexed: 11/29/2022] Open
Abstract
Use of negative pressure wound therapy (NPWT) in peripheral artery disease (PAD) and diabetic limb salvage (DLS) improves wound healing by providing moist wound conditions, reducing exudate, controlling wound-bed infection, and stimulating granulation. NPWT duration may take several weeks, and home-based NPWT allows patient to recover in the community while minimising risks of prolonged hospitalisation. The aim of this study is to review the use and outcomes of home NPWT in PAD and DLS. The methodology is the retrospective review of patients who were discharged with home NPWT after in-patient PAD revascularisation and DLS debridement or minor amputations. The results included a total of 118 patients who received home NPWT between January 2017 and December 2017. The mean age was 62.8 years with 66% male and 34% female patients. The study population comprised 25% smokers, 98% patients with diabetics, 35% with ischemic heart disease, and 21% with end-stage renal failure (ESRF). Of which, 56% of patients required revascularisation while 31% of patients underwent foot debridement, 48% underwent toe amputations, and 20% underwent forefoot amputations. All patients received in-patient NPWT for a week before being discharged on home NPWT for 4 weeks. Then, 62% received targeted antibiotics regime while 36% received empirical antibiotics on discharge; 60% of patients achieved wound healing on home NPWT, with 9% requiring split-thickness skin graft; 4% required further surgical debridement, 16% required further minor amputation while 20% required major amputation. 9% required further home NPWT extension, with a mean length of 7.1 ± 4.7 weeks' extension. Overall survival of 1 year was 89%. Risk factors that predict the failure of home NPWT includes subjects with a background of ESRF and wet gangrene on presentation. Home NPWT is a useful adjunct in the management of PAD and DLS foot wounds.
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Affiliation(s)
- Kai Lim
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Xuxin Lim
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Qiantai Hong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Enming Yong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Sadhana Chandrasekar
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Glenn W L Tan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Zhiwen J Lo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
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23
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He Y, Wu Z, Qiu C, Wang X, Xiang Y, Lu T, He Y, Shang T, Zhu Q, Wang X, Zeng Q, Zhang H, Li D. Long non-coding RNA GAPLINC promotes angiogenesis by regulating miR-211 under hypoxia in human umbilical vein endothelial cells. J Cell Mol Med 2019; 23:8090-8100. [PMID: 31589383 PMCID: PMC6850972 DOI: 10.1111/jcmm.14678] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 08/19/2019] [Accepted: 08/29/2019] [Indexed: 12/18/2022] Open
Abstract
In this study, we investigated the role of a long non‐coding RNA GAPLINC in angiogenesis using human umbilical vein endothelial cells (HUVEC). We found that hypoxia and hypoxia‐inducible factor 1α (HIF‐1α) increased the expression of GAPLINC in HUVEC cells. Moreover, GAPLINC overexpression down‐regulated miR‐211 and up‐regulated Bcl2 protein expression. Further rescue experiments confirmed that hypoxia directly increased GAPLINC expression. GAPLINC overexpression also increased cell migration and vessel formation which promoted angiogenesis, and these changes were attributed to the increased expression of vascular endothelial growth factor receptors (VEGFR) and delta‐like canonical notch ligand 4 (DLL4) receptors. Finally, we demonstrated that GAPLINC promotes vessel formation and migration by regulating MAPK and NF‐kB signalling pathways. Taken together, these findings comprehensively demonstrate that overexpression of GAPLINC increases HUVEC cells angiogenesis under hypoxia condition suggesting that GAPLINC can be a potential target for critical limb ischaemia (CLI) treatment.
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Affiliation(s)
- Yangyan He
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hang Zhou, China
| | - Ziheng Wu
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hang Zhou, China
| | - Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hang Zhou, China
| | - Xiaohui Wang
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hang Zhou, China
| | - Yilang Xiang
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hang Zhou, China
| | - Tian Lu
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hang Zhou, China
| | - Yunjun He
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hang Zhou, China
| | - Tao Shang
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hang Zhou, China
| | - Qianqian Zhu
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hang Zhou, China
| | - Xun Wang
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hang Zhou, China
| | - Qinglong Zeng
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hang Zhou, China
| | - Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hang Zhou, China
| | - Donglin Li
- Department of Vascular Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hang Zhou, China
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24
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Cherviakov IV, Kha KN, Gavrilenko AV, Klimov AE. [Differentiated approach to treatment of decompensated lower limb ischaemia with the use of the WIFI classification system]. Angiol Sosud Khir 2019; 25:9-16. [PMID: 30994602 DOI: 10.33529/angio2019101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In the present article, the authors substantiate the necessity of subdividing a heterogeneous cohort of patients presenting with Fontaine-Pokrovsky grade IV critical limb ischaemia into subgroups with the aim of making an appropriate therapeutic decision and predicting the outcome. We also translated into the Russian language the WIfI classification system developed by the Society for Vascular Surgery (2014) in order to predict limb loss and feasibility of performing revascularization. This is followed by comments on the classification, accompanied by examples of own clinical case studies. In order to check-up the ability of the SVS WIfI classification system to predict the one-year risk of major amputation in patients with decompensated ischaemia, we carried out a retrospective multicenter study, enrolling a total of 109 patients with unreconstructable stage IV chronic ischaemia. Our primary endpoint was the frequency of major amputation during the first year of follow up. The patients were divided into 4 subgroups based on a combination of the three WIfI domains, i. e., wound, ischaemia, and foot infection, respectively, as follows: 130 - 27% (n=29), 131 - 23% (n=25), 230 - 20% (n=22), and 231 - 30% (n=33). The frequency of amputation during the first year of follow-up with the natural course of the disease on the background of conventional therapy averagely amounted to 36%. By the WIfI component combinations, we revealed statistically significant differences between the subgroups (p=0.035): 130 - 21% (n=6), 131 - 28% (n=7), 230 - 36% (n=8), 231 - 55% (n=18). The WIfI classification makes it possible to predict the risk of major amputation in patients with limb-threatening ischaemia. The frequency of amputation during the first year of follow up in the natural course of the disease is associated not only with the WIfI clinical stage but also with the WIfI component combinations.
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Affiliation(s)
- Iu V Cherviakov
- Yaroslavl State Medical University of the RF Ministry of Public Health, Yaroslavl, Russia
| | - Kh N Kha
- Russian University of Friendship of Peoples, Moscow, Russia
| | - A V Gavrilenko
- Russian Research Centre of Surgery named after Academician B.V. Petrovsky, Moscow, Russia; First Moscow State Medical University named after I.M. Sechenov under the RF Ministry of Public Health, Moscow, Russia
| | - A E Klimov
- Russian University of Friendship of Peoples, Moscow, Russia
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25
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Nishijima A, Gosho M, Yoshida R, Yanagibayashi S, Takikawa M, Nishijima J, Sekido M, Yamamoto N. Effective wound bed preparation using maggot debridement therapy for patients with critical limb ischaemia. J Wound Care 2019; 26:483-489. [PMID: 28795888 DOI: 10.12968/jowc.2017.26.8.483] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Patients with critical limb ischaemia (CLI) lack sufficient blood flow in to the limb, which leads to difficulties in the normal wound healing process. Therefore, maggot debridement therapy (MDT) has not generally been recommended for CLI patients. We evaluated the effectiveness of wound bed preparation by MDT in CLI patients who had undergone mid-foot amputation. METHODS Patients who underwent mid-foot amputation after angioplasty between April 2014 and October 2016 were retrospectively investigated by classifying them into an MDT group or a conventional treatment group. The primary outcome was defined as achievement of wound healing. Secondary outcomes were the proportions of amputation-free survival (AFS) and successful ambulatory improvement. Propensity scores were used to evaluate treatment outcomes based on five factors: ankle-brachial index, skin perfusion pressure of the foot, nutritional status, experience with dialysis and age. RESULTS A total of 39 patients (39 legs) were included, seven within the MDT group and 32 in the conventional treatment group. Clinical backgrounds of the two groups showed no significant differences except for higher albumin levels for the MDT group (3.5±0.4g/dl; p=0.014). The wound healing proportion was significantly higher in the MDT group (86%) than in the control group (38%) (p=0.035). At 6 months after amputation, no significant differences were found between the two groups for AFS (71% versus 47%; p=0.41) or ambulatory capability (43% versus 28%; p=0.65). This result was also similar to the propensity score adjustment analysis. CONCLUSIONS The efficacy of MDT with favourable wound bed preparation was shown in our CLI patients based on effective debridement and granulation formation by maggots, avoiding the loss of their heels. Wound-healing rates after MDT were higher for patients than for those receiving conventional treatment. MDT is considered a valid adjuvant treatment strategy for patients with CLI after revascularisation treatment is conducted. More favourable wound bed preparation and successful graft take were achieved in the MDT group, suggesting the effectiveness of MDT for wound healing in CLI patients.
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Affiliation(s)
- A Nishijima
- Department of Plastic and Reconstructive Surgery, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba 270-2232, Japan
| | - M Gosho
- Department of Clinical Trial and Clinical Epidemiology, Faculty of Medicine, University of Tsukuba, Ibaraki 305-8576, Japan
| | - R Yoshida
- Department of Plastic and Reconstructive Surgery, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba 270-2232, Japan
| | - S Yanagibayashi
- Department of Plastic and Reconstructive Surgery, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba 270-2232, Japan
| | - M Takikawa
- Department of Plastic and Reconstructive Surgery, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba 270-2232, Japan
| | - J Nishijima
- Department of Plastic and Reconstructive Surgery, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba 270-2232, Japan
| | - M Sekido
- Department of Plastic and Reconstructive Surgery, University of Tsukuba, 2-1-1 Amakubo, Tsukuba, Ibaraki 305-8576, Japan
| | - N Yamamoto
- Department of Plastic and Reconstructive Surgery, New Tokyo Hospital, 1271 Wanagaya, Matsudo, Chiba 270-2232, Japan
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26
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Ionescu CN, Altin SE, Mena-Hurtado C. Antiplatelet therapy for tibial balloon angioplasty: A clinical perspective. SAGE Open Med 2019; 7:2050312119854579. [PMID: 31210934 PMCID: PMC6545680 DOI: 10.1177/2050312119854579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 05/13/2019] [Indexed: 12/24/2022] Open
Abstract
Percutaneous transluminal tibial balloon angioplasty has an important role in the therapeutic approach of critical limb ischaemia. Despite a growing number of patients with critical limb ischaemia, there are no trials to guide the pharmacologic approach post intervention. Guidelines pertaining to the antiplatelet therapy post percutaneous transluminal tibial balloon angioplasty have not been developed. In addition, critical limb ischaemia patients have multiple comorbidities and a higher risk of bleeding. To examine the shortest duration of antiplatelet therapy post percutaneous transluminal tibial balloon angioplasty, we reviewed the preclinical data used to develop the standards for the current angioplasty technique.
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Affiliation(s)
- Costin N Ionescu
- Cardiovascular Disease Section, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sophia E Altin
- Cardiovascular Disease Section, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Cardiovascular Disease Section, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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27
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Al Shakarchi J, Inston N, Dabare D, Newman J, Garnham A, Hobbs S, Wall M. Pilot study on the use of infrared thermal imaging to predict infrainguinal bypass outcome in the immediate post-operative period. Vascular 2019; 27:663-667. [PMID: 31067207 DOI: 10.1177/1708538119847391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives Early bedside post-operative monitoring of infrainguinal bypass surgery is currently based on subjective clinical findings and handheld Doppler signals. Infrared thermal imaging is an objective and reproducible technique that has been proven to be a reliable and accurate method to measure skin temperature. The aim of this prospective study was to assess infrared thermal imaging as a predicting tool of bypass graft outcome in the immediate post-operative period and assess the angiosome concept. Methods This was a prospective cohort study of 25 patients undergoing infrainguinal bypass. Demographic and clinical data were prospectively collected and included gender, age, co-morbidities, pre- and post-operative ankle brachial pressure indices, surgery undertaken and patency of run-off vessels. Infrared thermal imaging was undertaken pre- and post-operatively to assess thermal changes to the feet following revascularisation. Results We found that an increase in temperature from pre- to post-operative was significantly associated with bypass patency. An increase in temperature was found to have a positive predictive value of 75%, a negative predictive value of 100%, a sensitivity of 100% and specificity of 89% for predicting graft patency. Conclusions Infrared thermal imaging can be used to measure temperature related changes of the microcirculation post-operatively and predict bypass outcomes in the immediate post-operative period.
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Affiliation(s)
- J Al Shakarchi
- Department of Vascular Surgery, Black Country Vascular Network, Dudley, UK
| | - N Inston
- Department of Renal Surgery, University Hospital Birmingham, Birmingham, UK
| | - D Dabare
- Department of Renal Surgery, University Hospital Birmingham, Birmingham, UK
| | - J Newman
- Department of Vascular Surgery, Black Country Vascular Network, Dudley, UK
| | - A Garnham
- Department of Vascular Surgery, Black Country Vascular Network, Dudley, UK
| | - S Hobbs
- Department of Vascular Surgery, Black Country Vascular Network, Dudley, UK
| | - M Wall
- Department of Vascular Surgery, Black Country Vascular Network, Dudley, UK
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Monaro S, West S, Pinkova J, Gullick J. The chaos of hospitalisation for patients with critical limb ischaemia approaching major amputation. J Clin Nurs 2018; 27:3530-3543. [PMID: 29776002 DOI: 10.1111/jocn.14536] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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: 08/29/2017] [Revised: 04/10/2018] [Accepted: 05/08/2018] [Indexed: 01/23/2023]
Abstract
AIMS AND OBJECTIVES To illuminate the hospital experience for patients and families when major amputation has been advised for critical limb ischaemia (CLI). BACKGROUND CLI creates significant burden to the health system and the family, particularly as the person with CLI approaches amputation. Major amputation is often offered as a late intervention for CLI in response to the marked deterioration of an ischaemic limb, and functional decline from reduced mobility, intractable pain, infection and/or toxaemia. While a wealth of clinical outcome data on CLI and amputation exists internationally, little is known about the patient/family-centred experience of hospitalisation to inform preservation of personhood and patient-centred care planning. DESIGN Longitudinal qualitative study using Heideggerian phenomenology. METHODS Fourteen patients and 13 family carers provided a semistructured interview after advice for major amputation. Where amputation followed, a second interview (6 months postprocedure) was provided by eight patients and seven family carers. Forty-two semistructured interviews were audio-recorded and transcribed verbatim. Hermeneutic phenomenological analysis followed. RESULTS Hospitalisation for CLI, with or without amputation, created a sense of chaos, characterised by being fragile and needing more time for care (fragile body and fragile mind, nurse busyness and carer hypervigilance), being adrift within uncontrollable spaces (noise, unreliable space, precarious accommodation and unpredictable scheduling) and being confused by missed and mixed messages (multiple stakeholders, information overload and cultural/linguistic diversity). CONCLUSIONS Patients and families need a range of strategies to assist mindful decision-making in preparation for amputation in what for them is a chaotic process occurring within a chaotic environment. Cognitive deficits increase the care complexity and burden of family advocacy. RELEVANCE TO CLINICAL PRACTICE A coordinated, interprofessional response should improve systems for communication, family engagement, operation scheduling and discharge planning to support preparation, adjustment and allow a sense of safety to develop. Formal peer support for patients and caregivers should be actively facilitated.
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Affiliation(s)
- Susan Monaro
- Concord Repatriation General Hospital, Concord, NSW, Australia.,University of Sydney, Susan Wakil School of Nursing & Midwifery, NSW, Australia
| | - Sandra West
- University of Sydney, Susan Wakil School of Nursing & Midwifery, NSW, Australia
| | - Jana Pinkova
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Janice Gullick
- University of Sydney, Susan Wakil School of Nursing & Midwifery, NSW, Australia
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Matsushita K, Kwak L, Yang C, Pang Y, Ballew SH, Sang Y, Hoogeveen RC, Jaar BG, Selvin E, Ballantyne CM, Sharrett AR, Folsom AR, Heiss G, Coresh J, Hirsch AT. High-sensitivity cardiac troponin and natriuretic peptide with risk of lower-extremity peripheral artery disease: the Atherosclerosis Risk in Communities (ARIC) Study. Eur Heart J 2018; 39:2412-2419. [PMID: 29579246 PMCID: PMC6031056 DOI: 10.1093/eurheartj/ehy106] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/30/2017] [Accepted: 03/13/2018] [Indexed: 01/08/2023] Open
Abstract
Aims Cardiac troponin T (cTnT) is suggested as a predictor of amputation in patients with peripheral artery disease (PAD). However, cTnT-PAD association has not been systematically studied in a large study. This study evaluated the association of high-sensitivity cTnT (hs-cTnT) with PAD incidence and also explored whether natriuretic peptide (NT-proBNP), another representative cardiac marker, predicts PAD risk. Methods and results Among 12 288 middle-aged adults, the associations of hs-cTnT and NT-proBNP with incident PAD (hospitalizations with PAD diagnosis or leg revascularization [cases with rest pain or tissue loss considered as critical limb ischaemia (CLI)]) were quantified with multivariable Cox regression models. The risk discrimination was assessed by c-statistic. During a follow-up over 22 years, 454 participants developed PAD (164 CLI cases). In demographically adjusted models, the highest category of hs-cTnT (≥14 vs. <3 ng/L) and NT-proBNP (≥258.3 vs. <51.5 pg/mL) showed ∼8- and 10-20-fold higher risk of PAD and CLI, respectively. Even after adjusting for potential confounders and each other, hazard ratios were greater for CLI than for PAD (7.74 95% confidence interval [95% CI 4.43-13.55] vs. 2.84 [2.02-4.00] for the highest vs. reference hs-cTnT category and 4.63 [2.61-8.23] vs. 3.16 [2.23-4.49] for the highest vs. reference NT-proBNP category). The addition of these cardiac markers improved c-statistics for CLI. Conclusion High-sensitivity cTnT and NT-proBNP were independently associated with incident PAD, particularly its severe form, CLI. Although future studies are warranted to investigate pathophysiological mechanisms behind these associations, our study suggests the usefulness of cardiac markers to identify individuals at high risk of CLI.
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Affiliation(s)
- Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Lucia Kwak
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Chao Yang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Yuanjie Pang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Yingying Sang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Ron C Hoogeveen
- Department of Medicine, Section of Atherosclerosis and Vascular Medicine, Baylor College of Medicine, 6565 Fannin Street, Houston, TX, USA
| | - Bernard G Jaar
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, 1830 East Monument St., Baltimore, MD, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Christie M Ballantyne
- Department of Medicine, Section of Atherosclerosis and Vascular Medicine, Baylor College of Medicine, 6565 Fannin Street, Houston, TX, USA
| | - A Richey Sharrett
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Aaron R Folsom
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, West Bank Office Building, 1300 South Second Street, Minneapolis, MN, USA
| | - Gerardo Heiss
- University of North Carolina at Chapel Hill Gillings School of Global Public Health, 123 W. Franklin Street, Chapel Hill, NC, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 2024 E. Monument Street, Baltimore, MD, USA
| | - Alan T Hirsch
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, 1830 East Monument St., Baltimore, MD, USA
- University of Minnesota Medical School, Mayo Building, 420 Delaware Street SE, Minneapolis, MN, USA
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Nishijima A, Yamamoto N, Yoshida R, Yanagibayashi S, Takikawa M, Hayasaka R, Maruyama E, Nishijima J, Sekido M. Maggot debridement therapy with a direct dressing can cause compression injuries in patients with chronic limb ischemia. Case Reports Plast Surg Hand Surg 2017; 4:84-88. [PMID: 28971112 PMCID: PMC5613910 DOI: 10.1080/23320885.2017.1373596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 08/28/2017] [Indexed: 11/02/2022]
Abstract
While there are no reports regarding dressing-associated iatrogenic skin ulcer as an adverse event of maggot debridement therapy (MDT), MDT is clinically used on patients with critical limb ischaemia with dermal fragility. Herein we report causes and counter measures for a case of iatrogenic skin ulcer induced by MDT dressing.
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Affiliation(s)
- Akio Nishijima
- Department of Plastic and Reconstructive Surgery, New Tokyo HospitalMatsudoChibaJapan
| | - Naoto Yamamoto
- Department of Plastic and Reconstructive Surgery, New Tokyo HospitalMatsudoChibaJapan
| | - Ryuichi Yoshida
- Department of Plastic and Reconstructive Surgery, New Tokyo HospitalMatsudoChibaJapan
| | - Satoshi Yanagibayashi
- Department of Plastic and Reconstructive Surgery, New Tokyo HospitalMatsudoChibaJapan
| | - Megumi Takikawa
- Department of Plastic and Reconstructive Surgery, New Tokyo HospitalMatsudoChibaJapan
| | - Rie Hayasaka
- Department of Plastic and Reconstructive Surgery, New Tokyo HospitalMatsudoChibaJapan
| | - Eri Maruyama
- Department of Plastic and Reconstructive Surgery, New Tokyo HospitalMatsudoChibaJapan
| | - Junko Nishijima
- Department of Plastic and Reconstructive Surgery, New Tokyo HospitalMatsudoChibaJapan
| | - Mitsuru Sekido
- Department of Plastic and Reconstructive Surgery, University of TsukubaTsukubaIbarakiJapan
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Carlisi E, Caspani P, Morlino P, Bardoni MT, Lisi C, Bejor M, Dalla Toffola E. Early rehabilitative treatment after infrainguinal lower limb bypass surgery. Acta Biomed 2017; 88:167-171. [PMID: 28845831 PMCID: PMC6166142 DOI: 10.23750/abm.v88i2.5035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 01/13/2016] [Indexed: 11/23/2022]
Abstract
Background and aim of the work: Functional activity may remain limited in patients affected by critical limb ischemia, despite successful infrainguinal lower limb bypass surgery (ILLBS). The aim of the work was to evaluate the impact of a rehabilitative intervention on postoperative ambulatory status and pain. Methods: In an observational study, data were collected on 34 patients undergoing ILLBS for critical limb ischemia or end-stage peripheral arterial disease. All patients underwent a postoperative rehabilitation program aimed at recovering gait autonomy. Information was collected on pre-operative comorbidities, ambulatory status (on admission to and discharge from hospital) and pain in the affected lower limb (on the first physiotherapy session and at discharge). Results: Before ILLBS, 61.8% of the patients walked independently without aids or assistance. The rehabilitative program started on average 5.7 (SD: 2.1) days after surgery. At discharge, 50% of the patients walked independently, 41.2% walked with aids and/or assistance and 8.8% were not able to walk. Overall, 76.5% of the sample recovered their pre-operative ambulatory status. Although pain tended to decrease, the difference at the first (1.5; SD: 2.6) and at the last treatment session (0.8; SD= 1.3) was not statistically significant. Conclusion: Our exercise protocol resulted to be easy to perform during hospital stay, with an overall favourable outcome for ambulatory status. Our results are in line with those reported in literature about the rates of postoperative dependence in walking, but appear to be slightly better in regards to the percentage of patients who recovered pre-operative ambulatory status. (www.actabiomedica.it)
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Affiliation(s)
- Ettore Carlisi
- Physical Medicine and Rehabilitation Unit, I.R.C.C.S. Policlinico San Matteo Foundation & University of Pavia, Pavia.
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Monaro S, West S, Gullick J. An integrative review of health-related quality of life in patients with critical limb ischaemia. J Clin Nurs 2017; 26:2826-2844. [PMID: 27808440 DOI: 10.1111/jocn.13623] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2016] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To examine the domains and the domain-specific characteristics within a peripheral arterial disease health-related quality of life framework for their usefulness in defining critical limb ischaemia health-related quality of life. BACKGROUND Critical Limb Ischaemia presents a highly individualised set of personal and health circumstances. Treatment options include conservative management, revascularisation or amputation. However, the links between treatment decisions and quality of life require further investigation. DESIGN The framework for this integrative review was the peripheral arterial disease-specific health-related quality of life domains identified by Treat-Jacobson et al. RESULTS The literature expanded and refined Treat-Jacobson's framework by modifying the characteristics to better describe health-related quality of life in critical limb ischaemia. CONCLUSIONS Given that critical limb ischaemia is a highly individualised situation with powerful health-related quality of life implications, further research focusing on patient and family-centred decision-making relating to therapeutic options and advanced care planning is required. RELEVANCE TO CLINICAL PRACTICE A critical limb ischaemia-specific, health-related quality of life tool is required to capture both the unique characteristics of this disorder, and the outcomes for active or conservative care among this complex group of patients.
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Affiliation(s)
- Susan Monaro
- Concord Repatriation General Hospital, Concord, NSW, Australia.,Sydney Nursing School, University of Sydney, Sydney, NSW, Australia
| | - Sandra West
- Sydney Nursing School, University of Sydney, Sydney, NSW, Australia
| | - Janice Gullick
- Sydney Nursing School, University of Sydney, Sydney, NSW, Australia.,Sydney Local Health District, Sydney, NSW, Australia
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Cury MVM, Brochado-Neto FC, Matielo MF, de Athayde Soares R, Sarpe AKP, Sacilotto R. Results of bypass graft surgery after prior angioplasty in critical limb ischaemia treatment. VASA 2016; 45:305-10. [PMID: 27428499 DOI: 10.1024/0301-1526/a000542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The aim of this study was to determine the outcomes of primary bypass graft surgery (BGS) compared to BGS after failed angioplasty (PTA). PATIENTS AND METHODS Between January 2007 and January 2014, we performed 136 BGSs exclusively for the treatment of critical limb ischaemia. Two cohorts were identified: 1) primary BGS (n = 102; group I), and 2) BGS after prior PTA (n = 34; group II). Data were analysed retrospectively and the primary endpoints were the rates of secondary patency, amputation-free survival, freedom from major adverse outcomes (graft occlusion, amputation, or death), and overall survival, which were assessed with the Kaplan-Meier method. RESULTS Both groups were comparable with a predominance of Rutherford's category 5 ischaemic lesions (73.3 %). Most patients had extensive TASC D athe-rosclerotic disease (83.6 %), and the main conduit was the greater saphenous vein (58.1 %). The mean follow-up time was 36.2 months. The 3-year secondary patency rates were better for group I (64.3 % vs 49.6 %; P = 0.04). During the same period, the amputation-free survival rates were similar between the groups (77.4 % vs 74.5 %; P = 0.59). For multivariate Cox regression analysis, BGS after prior PTA was the only factor associated with re-intervention for limb salvage (hazard ratio = 2.39; CI 95 % = 1.19 - 4.80; P = 0.02). At the 3-year point, there were no differences in the overall survival rates (72.6 % vs 70 %; P = 0.97), but the proportion of patients without adverse outcomes was higher in group I (37.3 % vs 13.4 %; P = 0.007). CONCLUSIONS Although secondary patency was better after primary BGS, the amputation-free and overall survival rates support the use of BGS after prior PTA.
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Affiliation(s)
- Marcus Vinícius Martins Cury
- 1 Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo - HSPE, São Paulo, Brazil
| | - Francisco Cardoso Brochado-Neto
- 1 Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo - HSPE, São Paulo, Brazil
| | - Marcelo Fernando Matielo
- 1 Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo - HSPE, São Paulo, Brazil
| | - Rafael de Athayde Soares
- 1 Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo - HSPE, São Paulo, Brazil
| | - Anna Karina Paiva Sarpe
- 1 Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo - HSPE, São Paulo, Brazil
| | - Roberto Sacilotto
- 1 Department of Vascular and Endovascular Surgery, Hospital do Servidor Público Estadual de São Paulo - HSPE, São Paulo, Brazil
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Abstract
Restenosis or re-occlusion after femoropopliteal angioplasty or stent implantation is the main limitation of endovascular treatment strategies for peripheral artery disease. Within the last years, balloon catheters with anti-proliferative drug coating on the balloon surface have shown to be associated with higher patency rates compared to plain balloon angioplasty. Thus, drug-coated balloons were gradually adopted in many interventional centres for the treatment of femoropopliteal obstructions. The current review summarises the existing evidence for drug-coated balloons in the infrainguinal vessels and their indication in special lesion cohorts.
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Tay JS, Ching SS, Tan YK, Kum SWC. Endovascular retrograde recanalization in Asian critical limb ischaemia patients. ANZ J Surg 2016; 87:E61-E64. [PMID: 27255797 DOI: 10.1111/ans.13649] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 12/03/2015] [Revised: 04/09/2016] [Accepted: 05/11/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND To evaluate endovascular retrograde recanalization of critical limb ischaemia (CLI) patients with chronic total occlusions (CTOs) in an Asian population. METHODS We conducted a single centre-based retrospective review of CLI patients with CTOs who had undergone endovascular retrograde recanalization using the subintimal arterial flossing with antegrade-retrograde intervention technique. RESULTS A total of 40 CLI patients with CTOs underwent endovascular intervention. The median age was 71 years; 67.5% were males and Chinese accounted for 65% of the patients, of which 55% were in Rutherford category 6, 37.5% in category 5 and 7.5% in category 4. Antegrade-retrograde access was performed via the femoral artery in 39 cases and the brachial artery in one case for the proximal puncture, and the following arteries for the distal puncture: superficial femoral, n = 4 (10%); popliteal, n = 4 (10%); anterior tibial, n = 12 (30%); dorsalis pedis, n = 9 (22.5%); peroneal, n = 4 (10%) and posterior tibial, n = 7 (17.5%). Technical success was high at 92.5% (n = 37). After intervention, 25% (n = 10) had below-knee triple vessel runoff, 52.5% (n = 21) had double vessel runoff and 15.0% (n = 6) had single vessel runoff. Stenting for target vessel dissections was required in 12 patients. There were two cases of significant bleeding; one common femoral artery pseudoaneurysm was treated with ultrasound-guided thrombin injection and another case of distal puncture site bleeding only required compression. Limb salvage at 1 year was 92.5% (n = 37). CONCLUSION The subintimal arterial flossing with antegrade-retrograde intervention technique is safe with high technical success rates and acceptable outcomes in Asian CLI patients with CTOs.
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Affiliation(s)
- Jia Sheng Tay
- Department of General Surgery, Changi General Hospital, Singapore, Singapore
| | - Siok Siong Ching
- Department of General Surgery, Changi General Hospital, Singapore, Singapore
| | - Yih Kai Tan
- Department of General Surgery, Changi General Hospital, Singapore, Singapore
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Mills JL. Lower limb ischaemia in patients with diabetic foot ulcers and gangrene: recognition, anatomic patterns and revascularization strategies. Diabetes Metab Res Rev 2016; 32 Suppl 1:239-45. [PMID: 26455728 DOI: 10.1002/dmrr.2753] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 09/17/2015] [Accepted: 10/06/2015] [Indexed: 12/27/2022]
Abstract
The confluence of several chronic conditions--in particular ageing, peripheral artery disease, diabetes, and chronic kidney disease--has created a global wave of lower limbs at risk for major amputation. While frequently asymptomatic or not lifestyle limiting, at least 1% of the population has peripheral artery disease of sufficient severity to be limb threatening. To avoid the critical error of failing to diagnose ischaemia, all patients with diabetic foot ulcers and gangrene should routinely undergo physiologic evaluation of foot perfusion. Ankle brachial index is useful when measurable, but may be falsely elevated or not obtainable in as many as 30% of patients with diabetic foot ulcers primarily because of medial calcinosis. Toe pressures and skin perfusion pressures are applicable to such patients.
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Abstract
Critical limb ischaemia (CLI) is a severe form of peripheral arterial disease (PAD). CLI often causes disabling symptoms of pain and can lead to loss of the affected limb. It is also associated with increased risk of myocardial infarction, stroke and death from cardiovascular disease. The aims of management in patients with CLI are to relieve ischaemic pain, heal ulcers, prevent limb loss, improve function and quality of life and prolong survival. Here, current evidence regarding the medical management of CLI is reviewed. Cardiovascular risk factors should be assessed in all patients with CLI; smoking cessation and treatment of hypertension, hyperlipidaemia and diabetes all reduce the mortality rate in those with PAD. Antiplatelet agents (either aspirin or clopidogrel) are recommended to reduce both the incidence of cardiovascular events and risk of arterial occlusion. By contrast, routine use of anticoagulation (either warfarin or heparin) is not recommended. Treatment of the limbs themselves is often more challenging. Prostanoids may have some efficacy for treating rest pain and for ulcer healing, and iloprost shows favourable results in reducing the risk of major amputations, but long-term follow-up data regarding disease progression are lacking. There is insufficient evidence to support the use of naftidrofuryl or cilostazol, and pentoxifylline is not beneficial. Furthermore, there is no evidence of proven benefit of hyperbaric oxygen. A number of angiogenic growth factors have been studied in Phase I studies and randomized controlled trials (RCTs). They appear to be safe, but efficacy results have been mixed. Treatment with stem cells also shows some potential from early trials, but further larger RCTs are needed to demonstrate clear benefit. Thrombolysis may be an alternative for patients who develop acute limb ischaemia and are unsuitable for surgical intervention. However, newer endovascular techniques are likely to have a greater role in the future.
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Affiliation(s)
- M A Lambert
- Division of Cardiovascular and Diabetes Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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Dubsky M, Jirkovska A, Bem R, Fejfarova V, Pagacova L, Sixta B, Varga M, Langkramer S, Sykova E, Jude EB. Both autologous bone marrow mononuclear cell and peripheral blood progenitor cell therapies similarly improve ischaemia in patients with diabetic foot in comparison with control treatment. Diabetes Metab Res Rev 2013; 29:369-76. [PMID: 23390092 DOI: 10.1002/dmrr.2399] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 01/14/2013] [Accepted: 01/15/2013] [Indexed: 01/09/2023]
Abstract
BACKGROUND The aim of our study was to compare the effect of bone marrow mononuclear cell and peripheral blood progenitor cell therapies in patients with diabetic foot disease and critical limb ischaemia unresponsive to revascularization with conservative therapy. METHODS Twenty-eight patients with diabetic foot disease (17 treated by bone marrow cells and 11 by peripheral blood cell) were included into an active group and 22 patients into a control group without cell treatment. Transcutaneous oxygen pressure and rate of major amputation, as the main outcome measures, were compared between bone marrow cells, peripheral blood cell and control groups over 6 months; both cell therapy methods were also compared by the characteristics of cell suspensions. Possible adverse events were evaluated by changes of serum levels of angiogenic cytokines and retinal fundoscopic examination. RESULTS The transcutaneous oxygen pressure increased significantly (p < 0.05) compared with baseline in both active groups after 6 months, with no significant differences between bone marrow cells and peripheral blood cell groups; however, no change of transcutaneous oxygen pressure in the control group was observed. The rate of major amputation by 6 months was significantly lower in the active cell therapy group compared with that in the control group (11.1% vs. 50%, p = 0.0032), with no difference between bone marrow cells and peripheral blood cell. A number of injected CD34+ cells and serum levels of angiogenic cytokines after treatment did not significantly differ between bone marrow cells and peripheral blood cell. CONCLUSIONS Our study showed a superior benefit of bone marrow cells and peripheral blood cell treatments of critical limb ischaemia in patients with diabetic foot disease when compared with conservative therapy. There was no difference between both cell therapy groups, and no patient demonstrated signs of systemic vasculogenesis.
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Affiliation(s)
- M Dubsky
- Diabetes Centre, Prague, Czech Republic; First Medical Faculty, Charles University, Prague, Czech Republic.
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