Critical Lower Limb Ischemia Research Articles

Interobserver and inter-modality concordance of quiescent interval slice selective magnetic resonance angiography and CT angiography in assessment of critical lower limb ischemia

BackgroundWe evaluated the noncontrast MRA as an alternate method to CT angiography in assessment of patients with lower limb ischemia, 30 patients were included in a prospective cohort study; they underwent quiescent interval slice selective magnetic resonance angiography (QISS-MRA) and computed tomographic angiography (CTA). The assessment of images was evaluated by two independent consultants. The overall subjective image quality, interobserver and intermodality concordance were calculated.ResultsThe median acquisition time in QISS-MRA was 20 min (range 18–30 min), The overall subjective image quality was rated similarly with QISS-MRA (3.13 [95% CI 2.84–3.42]) and CTA (3.23 [95% CI 2.94–3.52]; p = 0.08) with interobserver concordance for lesion ratings in QISS-MRA reached (κ = 0.987 (SD 0.006)), while for CTA it was (κ = 0.99 (SD 0.006)), while the intermodality concordance between QISS-MRA and CTA in lesion ratings were calculated on a per segment basis and was (κ = 0.944 (SD 0.013)) for reader 1 and (κ = 0.947 (SD 0.013)) for reader 2, with sensitivity 100% and specificity 97.6%ConclusionsQISS-MRA is a reliable modality for assessment of patients with critical limb ischemia.

Directional Atherectomy for Critical Lower Limb Ischemia: A Retrospective Observational Study.

Chronic arterial obstructive disease of the lower limbs is a significant global health issue. Directional atherectomy offers advantages in treating critical ischemia. The objective of this study is to determine the clinical outcomes of patients with critical ischemia who underwent directional atherectomy using the TurboHawkdevice. A retrospective review was conducted at Alma Mater Hospital in Medellín, Colombia, on all medical records of patients with critical limb ischemia (Rutherford Classes V and VI) who underwent directional atherectomy for infra-inguinal arterial disease. A total of 42 atherectomies were performed in 41 patients, with 61% classified as Rutherford V and 24.4% as Rutherford VI. The average lesion length to be treated was 60 mm. Calcifications were found in 45.2% of cases, and predilatation angioplasty was used in 42.9% of cases. Atherectomy sites included femoropopliteal segment (40%), superficial femoral (29%), infrapopliteal vessels (14.2%), and more than one vessel in 50% of cases. Technical success was achieved in 78.6% of cases and procedural success in 97.6%, and the need for adjunctive conventional balloon angioplasty was 21.4%, while drug-coated balloon angioplasties were performed in 50% of limbs. The overall complication rate was 14.4%, with embolism at 4.8%, dissection at 4.8%, puncture at 2.4%, and perforation at 2.4%. The average follow-up duration was 12 months, and major amputations were required in 23.8% of cases. Improvement in ankle-brachial index to ≥0.1 was seen in 77% of limbs. Limb survival at 30 days was 85%, and at 90 days, it was 83%. The overall survival rate in the study was 79%. Directional atherectomy is a safe alternative for managing critical ischemia in Rutherford V and VI patients.

The case of endovascular treatment of an elderly patient with obliterating atherosclerosis and critical lower limb ischemia after suffering a new coronavirus infection complicated by thrombosis of the femoralpopliteal shunt

The case of endovascular treatment of an elderly patient with obliterating atherosclerosis and critical lower limb ischemia after suffering a new coronavirus infection complicated by thrombosis of the femoralpopliteal shunt

The Clinical Impact of Access Site Selection for Successful Thrombolysis and Intervention in Acute Critical Lower Limb Ischaemia (RAD-ALI Registry).

Background: Acute limb ischaemia (ALI) is of great clinical importance due to its consequent serious complications and high comorbidity and mortality rates. The purpose of this study was to compare the acute success and complication rates of CDT performed via transradial, transbrachial, and transfemoral access sites in patients with acute lower limb vascular occlusion and to investigate the 1-year outcomes of CDT and MT for ALI. Methods: Between 2008 and 2019, 84 consecutive patients with ALI were treated with CDT in a large community hospital. Data were collected and retrospectively analysed. The primary ("safety") endpoints encompassed major adverse events (MAEs), major adverse limb events (MALEs), and the occurrence of complications related to the access site. Secondary ("efficacy") endpoints included both technical and clinical achievements, treatment success, fluoroscopy time, radiation dose, procedure time, and the crossover rate to an alternative puncture site. Results: CDT was started with radial (n = 17), brachial (n = 9), or femoral (n = 58) access. CDT was technically successful in 74/84 patients (88%), but additional MT and angioplasty and/or stent implantation was necessary in 17 (20.2%) and 45 cases (53.6%), respectively. Clinical success was achieved in 74/84 cases (88%). The mortality rate at 1 year was 14.3%. The cumulative incidence of MAEs and MALEs at 12 months was 50% and 40.5%, respectively. After conducting multivariate analysis, history of Rutherford stage IIB (hazard ratio [HR], 3.64; 95% confidence interval [CI], 1.58-8.41; p = 0.0025), occlusion of the external iliac artery (HR, 27.52; 95% CI, 2.83-267.33; p = 0.0043), being a case of clinically unsuccessful thrombolysis (HR, 7.72; 95% CI, 2.48-23.10; p = 0.0004), and the presence of diabetes mellitus (HR, 2.18; 95% CI, 1.01-4.71; p = 0.047) were independent predictors of a high MAE mortality rate at 12 months. For MALEs, statistically significant differences were detected with the variables history of Rutherford stage IIB (HR, 4.30; 95% CI, 1.99-9.31; p = 0.0002) and external iliac artery occlusion (HR, 31.27; 95% CI, 3.47-282.23; p = 0.0022). Conclusions: Based on the short-term results of CDT, acute limb ischaemia can be successfully, safely, and effectively treated with catheter-directed thrombolytic therapy with radial, brachial, or femoral access. However, radial access is associated with fewer access site complications. A history of Rutherford stage IIB, occlusion of external iliac artery, unsuccessful thrombolysis, and the presence of diabetes mellitus were independently associated with an increased risk of MAEs. A history of Rutherford stage IIB and external iliac artery occlusion are independent predictors of MALEs.

Role of Retrograde Tibiopedal Access in Limb Salvage in Patients with Critical Lower Limb Ischemia

AbstractThe aim of this study was to assess the efficacy and safety of retrograde tibiopedal access as an alternative approach in cases of critical limb ischemia (CLI) when antegrade access has failed. A prospective study was conducted that included patients with CLI who underwent tibiopedal access after failed antegrade recanalization from January 2018 to June 2022. Follow-up was conducted at 6, 12, and 24 months. The primary outcomes evaluated were technical success rate and primary patency. Secondary outcomes included complication rate, mortality rate, and limb salvage rate (LSR). Forty-eight patients had CLI and Trans Atlantic Inter-Society Consensus infrainguinal lesions. The retrograde approach was used through the anterior tibial artery in 28 patients (58%), the posterior tibial artery in 18 patients (37.5%), and the peroneal artery in 2 patients (4.5%). Technical success was achieved in 90% of patients (43 patients). There was a significant increase in the anklebrachial index after the procedure with a mean follow-up of 22 months. Twenty-two months primary patency rate was 85.2%, while secondary patency rate was 100% and LSR was 96%, respectively. There was no mortality in the series. Retrograde tibiopedal approach is an alternative option for managing peripheral arterial disease and CLI. This method offers another means of crossing lesions when antegrade access failed, and the intervention can be completed either in an antegrade or retrograde approach. As the retrograde approach does not impact access site, considered a feasible safe treatment alternative which increase the success rate of endovascular treatment.

First experience of distal hybrid surgery on lower limb arteries with port-system installation

Cases of occlusive lesions of the arteries of the lower leg occupy a special place in the treatment of critical lower limb ischemia. In this regard, performing open reconstructive interventions is unpromising. A new era in the treatment of occlusions of the arteries of the lower leg has become endovascular surgery. However, due to extensive occlusive lesions of the arteries of the lower leg, direct endovascular revascularization is often impossible. Currently, vascular surgeons adhere to the angiosome principle, according to which the goal of balloon angioplasty is to restore blood supply to the artery supplying the angiosome with purulent-trophic changes. In the clinical example provided, the universality of the angiosome theory is questioned, and clinical success achieved due to the discovery of collateral blood fl ow is demonstrated. The patient underwent surgery with the use of an original hybrid operation technique with the installation of a port system followed by active therapeutic-diagnostic measures on an outpatient basis for 30 days. As a result of the treatment, epithelialization of the trophic defect and cessation of critical ischemic phenomena were noted.

Possibilities of Therapeutic Angiogenesis in Patients with Critical Lower Limb Ischemia

Two clinical observations of effective treatment of patients with critical ischemia of the lower extremities using plasma-free lysate autologous platelets. Both patients were male, 73 and 53 years old. Both were diagnosed with total damage to the arteries of the infrainguinal zone. One of them had previously undergone endarterectomy from the femoral artery with subsequent thrombosis. After examination and joint discussion with x-ray endovascular surgeons, they were found inoperable. Due to the ineffectiveness of standard conservative therapy, the patient was offered local administration of plasma-free lysate autologous platelets. After receiving written informed consent, the procedure for collecting venous blood and obtaining plasma-free lysate autologous platelets and the introduction of this drug into the muscles of the leg from the side of ischemia according to the original method. The method for assessing microcirculation was three-phase scintigraphy : before treatment, both patients showed a significant decrease in the inclusion of osteotropic radiopharmaceutical in the soft tissues of the legs. For areas of radiopharmaceutical hyperfixation, relative accumulation coefficients were calculated: for one patient, the calculation results demonstrated the formation of foci of aseptic necrosis. When patients were re-hospitalized after 6 months, there was an improvement in local status and relief of rest pain. According to scintigraphy, a significant improvement in microcirculation was noted; no foci of aseptic necrosis were identified. Thus, the use of plasma-free lysate autologous platelets in combination with complex conservative therapy has demonstrated positive results; this method can be considered as an alternative revascularization ischemic limb.

Lipid Metabolism Disorders and its Correction in Patients with Critical Lower Limb Ischemia During Revascularizing Osteotrepanation with Intramedullary Laser Irradiation Using Intravenous Laser Irradiation and Cytokine Therapy in the Perioperative Period

Lipid Metabolism Disorders and its Correction in Patients with Critical Lower Limb Ischemia During Revascularizing Osteotrepanation with Intramedullary Laser Irradiation Using Intravenous Laser Irradiation and Cytokine Therapy in the Perioperative Period

Role of Retrograde Tibiopedal Access in Patients With Critical Lower Limb Ischaemia: Challenges and Outcome

Role of Retrograde Tibiopedal Access in Patients With Critical Lower Limb Ischaemia: Challenges and Outcome

Endovascular treatment of deep femoral artery lesion in high-risk patients with critical lower limb ischemia

Endovascular treatment of deep femoral artery lesion in high-risk patients with critical lower limb ischemia

Optimal method for harvesting and preserving the reversed autologous vein before extended bypass grafting in patients with critical lower limb ischemia

Optimal method for harvesting and preserving the reversed autologous vein before extended bypass grafting in patients with critical lower limb ischemia

Superficial venous arterialization with the great saphenous vein in situ: a single-center experience.

Arterialization of the dorsal venous arch of the foot is a technique indicated in cases of critical lower limb ischemia that do not have a distal bed that is adequate to enable conventional treatment such as revascularization, angioplasty, or clinical treatment. The purpose of this study is to present the result of arterialization of the venous arch of the foot in 16 patients who underwent treatment with this technique. This is a cross-sectional retrospective descriptive analytical study based on a review of the medical records of 16 patients who underwent arterialization of the dorsal venous arch of the foot for limb salvage from January 2016 to January 2021. Four (25%) of the 16 patients who underwent arterialization of the venous arch of the foot underwent a major amputation during the same hospital stay and one patient (6.25%) had a major amputation within 6 months. The other 11 patients (68.75%) had their limbs preserved, with 10 undergoing minor amputations (toes and forefoot) and one patient having no additional procedures. We conclude that the technique of arterialization of the dorsal venous arch of the foot should be considered in selected cases. It is a valid alternative for limb salvage when conventional treatment is impossible.

TCT-144 The Clinical Impact of Access Site Selection for Local Thrombolysis and Intervention in Acute Critical Lower Limb Ischemia

TCT-144 The Clinical Impact of Access Site Selection for Local Thrombolysis and Intervention in Acute Critical Lower Limb Ischemia

One-year comparison of revascularizations for critical lower limb ischemia with infrageniculate autologous or allogenic venous bypass

One-year comparison of revascularizations for critical lower limb ischemia with infrageniculate autologous or allogenic venous bypass

The use of an aortic allograft in infection of an aortic prosthesis in a patient with a multi-storey lesion of the arterial bed of the lower extremities

The article presents a clinical case of treatment of patient K, 61 years old, with previously performed aorto-femoral bifurcation bypass surgery for critical lower limb ischemia. 6 months after the initial surgery, the patient developed thrombosis of the right arm of the prosthesis. After another 3 months, a persistent subfebrile body temperature appeared, multiple fistula passages formed with the release of pus in the areas of postoperative scars on the hips. Infection of a synthetic prosthesis was diagnosed. A decision was made to perform repeated surgical intervention in the volume of abdominal aortic reprosthetics with a cadaveric allograft. The surgery was performed at the clinic of the Faculty of Surgery of SamSMU: removal of the bifurcation synthetic prosthesis; rehabilitation of the prosthesis bed; reprosthetics of the aorta with vascular aortic allograft; endarterectomy from the deep artery of the thigh on both sides; bifurcation aorto-femoral reprosthetics; femoral-popliteal bypass with allograft on the right. The postoperative period was uneventful. Healing of wounds on the hips by secondary tension due to marginal skin necrosis. Critical limb ischemia was stopped. The patient was discharged on the 20th day in a satisfactory condition.CONCLUSION. The use of allografts makes it possible to perform reprosthetics of the abdominal aorta in case of infection of synthetic prosthesis and simultaneous reconstruction of the femoral-popliteal segment.

The Effectiveness of Subintimal Balloon Angioplasty in the Treatment of Critical Lower Limb Ischemia in Patients with Diabetes Mellitus

The aim of the study is to present the immediate and long-term results of treatment of patients with diabetic foot syndrome using subintimal balloon angioplasty.

Is Inframallolar Angioplasty Effective for Wound Healing in Patients with Critical Lower Limb Ischemia and Tibial Only Disease?

Background Prevalence of PAD is approximately 3–10% in the population as a whole, with this increasing to between 15 and 20% when focusing on older patients (> 70 years of age). Critical limb ischemia is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Aim of the Work The aim of the study is to assess the outcome of inframallelar angioplasty in patients with multiple tibial and pedal arch disease by the impact of technical success in the form of Angiogrophically improvement of pedal arch classification and clinical success by wound healing. Patient and Methods In this observational prospective study; 40 patients were selected from the Ain Shams University Hospitals either at OPC or ER. Patients were subjected to Duplex study and Computerized tomography (CT) angiography for investigation. Patients were treated by balloon angioplasty. Post-intervention medical treatment included: Anti-platelet, Acetylecysitene & fluids. Results Incomparison between the Complete Pedal Arch(CPA), Icomplete Pedal Arch(IPA), Absent Pedal Arch (APA) show no significant change demography and different comorbidities as regard age, gender, smoking, and other co-morbitidies as diabetes, hypertention, renal insufficiency, and obesity. Comparison between 3 groups in terms of wound healing show significant differnerence between CPA(91.7%), IPA (88.9%) and APA (50%) while non significant difference between CPA and IPA. In terms of healing duration it shows non significant difference between CPA and IPA, significant difference between IPA and APA and high significance diference between CPA and APA. Conclusion This is a prospective observational cohort study to asses the outcome of inframallelar angioplasty in patients with multiple tibial and pedal arch disease by the impact of technical success in the form of Angiogrophically improvement of pedal arch classification and clinical success by wound healing. Our study proved that inframalleolar angioplasty play effective role in improving the foot wound healing, shortening its duration in the chronic threatening limb ischemia patients, improving limb salvage and quality of life.

#4878 STUDYING THE EFFECTIVENESS OF PRASUGREL AND CLOPIDOGEL IN PATIENTS WITH CHRONIC LOWER LIMB ISCHEMIA WITH STAGE 2 CKD

Abstract Background and Aims To compare the clinical and rheological efficacy of prasugrel and clopidogrel in patients with chronic lower limb ischemia with stage 2 chronic kidney disease. According to statistics, in Europe, peripheral arterial disease is common in more than 40 million Europeans. According to the developed tactics, not only stroke should be recognized as a serious, life-threatening condition, but other peripheral vascular diseases can lead to disability and death. Methods The study included 101 patients with critical lower limb ischemia of atherosclerotic origin. The mean age of the patients was 51.51±8.33 years. As a control group, 20 healthy volunteers (mean age 53.90 ± 9.05 years) were examined without signs of pathology of the cardiovascular system, including those of a vegetative nature. All patients included in the study were hospitalized in the Department of Interventional Cardiology of the Republican Specialized Scientific and Practical Center for Therapy and Medical Rehabilitation, Tashkent city. Results In 94 patients (93.07%), CLCI was accompanied by hemodynamically significant multifocal atherosclerotic lesions. The first place in frequency of combined lesions was occupied by the coronary vessels, the second place - by the arteries of the brachiocephalic basin. 82 patients (81.19%) had previously suffered arterial occlusion, also most often in the form of acute myocardial infarction, somewhat less often - acute cerebrovascular accident. 47 patients (46.53%) underwent revascularization earlier, mainly coronary artery stenting, coronary artery bypass grafting, carotid endarterectomy. 8 patients (7.92%) underwent revascularization of the contralateral leg. The study studied spontaneous (SAT) and ADP-induced platelet aggregation. In the CG, SAT was noted only in 50% of cases and in all patients of the CLCI group. After comparing the results in the groups of patients with CLCI and representatives of the CG, in whom SAT was noted, it was found that both the rate and degree of SAT in the group of patients were significantly higher than in healthy individuals (2.95±0.59% versus 0.55± 0.21% and 6.05±1.54% versus 1.24±0.21%, respectively, p<0.001 significance of the intergroup difference of both parameters). All patients due to CINC underwent endovascular revascularization of the affected leg. After the procedure, patients were prescribed an antiplatelet agent at a maintenance dose (prasugrel 10 mg/day, clopidogrel 75 mg/day). After 3 months, a control examination was carried out, during which the dynamics of platelet aggregation activity was studied. It was found that the indicators of CAT and ADP induced aggregation decreased by 22-37%. During the test, patients with resistance to antiplatelet agents were identified - in whom the decrease in the degree of ADP5 induced aggregation was less than 20%. Such resistance was found in 19 patients: 1 patient in the prasugrel group (1.69%) and 18 patients in the clopidogrel group (42.86%, chi square = 27.00, p<0.001). Isolation of patients with normal and reduced response to the loading dose of clopidogrel revealed some differences (Table 3.3). So, already initially in this group of patients, the degree of ADP5-induced aggregation was lower than in the group of patients with an antiplatelet response of more than 20%. After the application of a loading dose of clopidogrel, differences in relative dynamics were noted only in terms of the degree of ADP%-induced aggregation (p<0.001). Conclusions Thus, the present study revealed that in patients with CLCI, there is a significant activation of CAT and an increase in the aggregation response to the introduction of high doses of the inducer of ADP5 aggregation. The loading dose of antiplatelet agents contributed to a significant decrease in platelet aggregation activity after 2 hours with a large effect of prasugrel. Chronic antiplatelet therapy led to a decrease in the rate and degree of aggregation, both spontaneous and ADP-induced, a decrease in the endogenous ADP release response, also with a great effect in patients taking prasugrel.

Anticoagulant therapy in a hemodialysis patient at high risk of thrombotic and hemorrhagic complications. Case report

An attempt to preserve the knee joint in a patient on hemodialysis with stage IV lower limb ischemia with a high risk of thrombotic and hemorrhagic complications is presented. Multifocal atherosclerosis and extensive occlusion of the arteries of the lower leg ruled out the technical possibility of revascularization. The patient refused the proposed hip amputation. An attempt was made to perform amputation at the level of the lower leg. Required therapy aimed at the treatment and prevention of thrombotic complications, and optimization of microcirculation in the ischemic limb. For this purpose, a prolonged blockade of the sciatic and femoral nerves, combined anticoagulant therapy, and treatment with alprostadil were performed. Therapy with antithrombotic and vasoactive drugs was not effective and was complicated by the state of persistent hypocoagulation with an episode of bleeding. Amputation of the limb at the level of the thigh was performed according to vital indications after correction of hypocoagulation. The lack of clinical recommendations on anticoagulant therapy for critical lower limb ischemia in patients with stage 5 chronic kidney disease requires an individual approach to the choice of antithrombotic drugs and their doses, monitoring the state of blood coagulation using an integral method for assessing the hemostasis system thromboelastography.

Prevention of gastrointestinal bleeding in patients after endovascular surgery on the arteries of the lower extremities for critical ischemia in diabetes mellitus

Relevance: Patients with critical lower limb ischemia and diabetes mellitus are the most difficult group of patients in terms of a favorable outcome of the disease. The number of such patients increases annually. When treating these patients, it is necessary to take into account many different pathological conditions that can lead to fatal complications in the perioperative period. The purpose of the work: The aim of the work was to study methods of prevention of gastrointestinal bleeding in patients after endovascular surgery on the arteries of the lower extremities for critical ischemia in diabetes mellitus. Material and methods: The prospective study included 220 patients who were treated in the vascular surgery department of the A. A. Polyantsev General Surgery Clinic of the Volgograd State Medical University for obliterating atherosclerosis of the arteries of the lower extremities and diabetes mellitus in the period from 2017 to 2021 inclusive. All patients were diagnosed with critical ischemia of the lower extremities stage IIIIV ischemia according to the Fontaine-Pokrovsky classification. Results and discussion. The relationship between the number of painkillers taken per day to reduce pain syndrome and erosive and ulcerative lesions of the gastric mucosa and duodenum in both groups was noted. Conclusion: All patients with peripheral artery diseases accompanied by critical ischemia had endoscopic changes from gastritis to ulcerative lesions, including those complicated by bleeding, by the time they sought specialized medical care. The group at increased risk of gastrointestinal bleeding is patients with repeated reconstructions, surgical corrections of complications or amputations at various levels (from finger to hip), as well as taking anticoagulants in therapeutic dosage. Routine prevention of gastrointestinal bleeding with proton pump inhibitors is not acceptable for this group of patients.