Critical Limb Ischemia Patients Research Articles

Determinants of Optimal Medical Therapy in Patients with Chronic Limb-threatening Ischemia

The utilization of optimal medical therapy (OMT) in patients with critical limb ischemia (CLI) has not been well studied. BEST-CLI is a National Institutes of Health-sponsored multicenter randomized controlled trial comparing revascularization strategies in CLI patients. We evaluated OMT-associated variables within BEST-CLI at baseline and analyzed their association with patient characteristics.

Circulating Biomarkers of Endothelial Dysfunction and Inflammation in Predicting Clinical Outcomes in Diabetic Patients with Critical Limb Ischemia.

Critical limb ischemia (CLI) is a severe manifestation of peripheral artery disease characterized by ischemic pain, which is frequently associated with diabetes and non-healing lesions to inferior limbs. The clinical management of diabetic patients with CLI typically includes percutaneous transluminal angioplasty (PTA) to restore limb circulation and surgical treatment of diabetic foot ulcers (DFU). However, even after successful treatment, CLI patients are prone to post-procedure complications, which may lead to unplanned revascularization or foot surgery. Unfortunately, the factors predicting adverse events in treated CLI patients are only partially known. This study aimed to identify potential biomarkers that predict the disease course in diabetic patients with CLI. For this purpose, we measured the circulating levels of a panel of 23 molecules related to inflammation, endothelial dysfunction, platelet activation, and thrombophilia in 92 patients with CLI and DFU requiring PTA and foot surgery. We investigated whether these putative biomarkers were associated with the following clinical endpoints: (1) healing of the treated DFUs; (2) need for new revascularization of the limb; (3) appearance of new lesions or relapses after successful healing. We found that sICAM-1 and endothelin-1 are inversely associated with DFU healing and that PAI-1 and endothelin-1 are associated with the need for new revascularization. Moreover, we found that the levels of thrombomodulin and sCD40L are associated with new lesions or recurrence, and we show that the levels of these biomarkers could be used in a decision tree to assign patients to clusters with different risks of developing new lesions or recurrences.

Role of duplex-guided infragenicular angioplasty in saving limbs

Background/aim Critical limb ischemia (CLI) is known as ischemic rest pain at rest or tissue loss with peripheral arterial disease. Endovascular intervention has many advantages than surgical bypasses and it is used frequently with fragile patients, at the same time, it has many adverse effects for both surgeon and patient such as radiation effect for both and renal-induced nephropathy for the patient. Worldwide duplex-guided infragenicular angioplasty is a new method that has been started to emerge and to be a common technique in such patients, That is why the present study aims to assess the feasibility and efficacy of duplex-guided infragenicular angioplasty to save limbs and to detect if it is applicable or not. Patients and methods Twenty CLI patients were admitted to the vascular unit from 2015 to 2017 in Al-Zahraa University Hospital, Al-Azhar University, Cairo, Egypt. We included patients with good femoral pulse and significant infragenicular lesions. We excluded those with proximal outflow lesions and with acute embolic or thrombotic insults. Percutanous transluminal angioplasty was done to all the patients through ipsilateral femoral access by using 0.014 and 0.018 wires 4 F catheters and low-profile balloons, then we followed them clinically and with duplex ultrasound at 1, 3, 6, and 12 months with calculating the hemodynamic studies. Results The present study enrolled 20 patients, six (30%) of them are females and 14 (70%) males, with mean age of 59.2. The clinical history of smokers, cardiac, diabetics, renal, and hypertensive were 65, 60, 50, 85, and 80%, respectively. Technical success was 90%. Groin hematoma, distal thrombosis, and vessel perforation were technical complications, with 5% for each. Optimal procedural success was achieved in 70%, of suboptimal in 20%, and then we failed in 10%. Rest paint completely disappeared from 75% of patients. Sixteen limbs were saved postintervention, Kaplan–Meier curve showed 70% survival rate at 6 months, while at 9 months, the drop occurred to be 28%, which was still to be the percent at 12 months. Conclusion Modern duplex ultrasound can be used to map the arterial disease and to show guide wires, sheaths, balloons, and stents for the treatment of infragenicular arterial lesions. Also, it seems to be safe, easy and effective technique, a bedside procedure, and cost-effective as well. It has a crucial role in saving limbs for CLI patients.

SA1 Critical Appraisal of Real-World Evidence on the Clinical and Economic Outcomes Associated with Stent Use in Critical Limb Ischemia

Given the significant burden of critical limb ischemia (CLI), endovascular interventions with stent use remains challenging. Recognizing methodological and practical limitations which exist in conventional clinical trials, real-world evidence (RWE) is increasingly adopted in research for CLI management. This study assessed the quality and the comprehensiveness of RWE on the clinical and economic outcomes associated with below-the-knee (BTK) drug-eluting stents (DES) and bare-metal stents (BMS) in CLI patients.

Technical Approach to Percutaneous Femoropopliteal Bypass and Deep Vein Arterialization

In the management of patients with critical limb ischemia endovascular revascularization plays a crucial role improving amputation-free survival, ischemic rest pain, and wound healing. Endovascular standard of care of peripheral arterial occlusive disease involves angioplasty and/or stent placement. The following discussion is intended to familiarize interventional physicians with the rationale, physiological concepts, and technical approach to developing endovascular procedures-percutaneous femoropopliteal bypass and percutaneous deep vein arterialization. Percutaneous arterial bypass procedure is designed to treat long complex Trans-Atlantic Inter-Society Consensus C and D hemodynamically significant superficial femoral artery lesions by redirecting the flow of blood from the diseased arterial segment through a femoral vein conduit. Percutaneous deep vein arterialization is used for selected "no-option" critical limb ischemia patients who cannot undergo or have failed conventional endovascular and/or surgical revascularization due to extensive occlusion of the outflow arteries. It involves creation of an arteriovenous fistula between a tibial artery and a tibial vein, disruption of venous valves, and elimination of venous collaterals. The consequent arterialization of the distal venous bed enables delivery of oxygenated pressurized arterial blood to the ischemic tissues, stimulating angiogenesis and increasing flow in the existent collateral vessels, which in turn will improve limb salvage and amputation free survival.

Prospective study comparing drug coated balloons versus balloon angioplasty for management of critical limb ischemia patients with tibial occlusive disease

Background: For years interventionists have been searching for a technique of angioplasty to provide a reasonable patency without leaving something behind, and drug coated balloons came as the answer long waited with very promising preliminary results. This study aimed to compare between plain balloons and drug coated balloons as regard patency and limb salvage in treating tibial atherosclerotic occlusive disease. Methods: A prospective, randomized study. Patients with CTLI due to tibial atherosclerotic occlusive disease with or without concomitant inflow involvement are randomized into 2 groups, group A standard balloon angioplasty and group B drug coated balloons in a ratio of 2: 1. All patients were followed up for 12 months both clinically and radiologically for patency, limb salvage and wound healing. Results: No statistically significant differences were found regarding demographic data, co-morbidities, and risk factors between both groups. 93.3% of patients were diabetics. The one-year primary patency rates differ between the two approaches only at 12 months and was better for the DCB group (P-value 0.004). The one-year limb salvage rates didn’t differ between the two groups.

Abstract No. 504 Preliminary experience of computed tomography perfusion study for patients with peripheral arterial disease using intra-procedural intra-arterial contrast administration

The purpose of this study is to describe a preliminary experience of a catheter-directed foot computed tomography (CT) perfusion study for critical limb ischemia (CLI) patients and compare the findings between pre and post angioplasty.

Technical outcomes of below-the-elbow revascularization for upper extremity critical limb ischemia.

This study aims to report the technical results of below-the-elbow arterial revascularization in patients with critical hand ischemia. We retrospectively identified upper extremity critical limb ischemia patients treated with below-the-elbow arterial intervention between 2013 and 2017. Patient demographics, comorbidities, and procedural data were reviewed and technical success was evaluated. Seven patients with 12 arteries that were affected by critical hand ischemia were treated. All patients had a history of end-stage renal disease. The technical success rate was 83.3%. There were no major or minor complications. The average follow-up duration was 9months (2-26 months). One patient underwent a digital amputation at 8months. Arterial revascularization of the below-the-elbow arteries for critical hand ischemia is safe and technically feasible.

Return to work after cell transplantation in patients with angiitis-induced critical limb ischaemia and factors related: a single-centre retrospective cohort study

BackgroundAngiitis-induced critical limb ischaemia (AICLI) patients, who are usually young and have a high amputation rate, always lose their ability to return to the labour force. Return to work (RTW) not only indicates patients’ physical health, showing that they could undertake the work, but also demonstrates their psychological well-being. While cell transplantation showed satisfactory efficacy in limb salvage, few studies of AICLI patients’ RTW after transplantation have been reported.MethodsFrom May 2009 to May 2021, AICLI patients who underwent cell transplantation and completed no less than 12 months of follow-up were retrospectively enrolled. The primary endpoint was RTW. Patient demographics and characteristics of the ischaemic limbs were reviewed to analyse independent risk factors for RTW.ResultsA total of 171 AICLI patients (170 males) were enrolled with a mean age of 41.9 ± 9.6 years (range: 20–57 years). The 12-month and 24-month RTW cumulative rates were 69.4% (95% confidence interval [CI] 61.6–75.6%) and 70.1% (95% CI 62.3–76.2%), respectively. Age < 40 years (odds ratio [OR] 2.659, 95% CI 1.138–6.719) and preoperative occupation as a mental worker (OR 8.930, 95% CI 2.665–42.847) were identified as independent protective factors for RTW. Perioperative limb infection with ulcer or gangrene (OR 0.250, 95% CI 0.075–0.779) was identified as an independent risk factor.ConclusionAICLI patients who underwent cell transplantation usually had a satisfactory midterm RTW cumulative rate. AICLI patients < 40 years old with preoperative occupation as mental workers were more likely to return to work. Prevention of limb infection during the perioperative period is of great significance to RTW.

Skeletal muscle MiR-210 expression is associated with mitochondrial function in peripheral artery disease patients

Previous studies have demonstrated that circulating microRNA (miR)-210 levels are elevated in peripheral artery disease (PAD) patients. MiR-210 is known to be a negative regulator of mitochondrial respiration; however, the relationship between miR-210 and mitochondrial function has yet to be studied in PAD. We aimed to compare skeletal muscle miR-210 expression of PAD patients to non-PAD controls (CON) and to examine the relationship between miR-210 expression and mitochondrial function. Skeletal muscle biopsies from CON (n=20), intermittent claudication (IC) patients (n=20), and critical limb ischemia (CLI) patients (n=20) were analyzed by high-resolution respirometry to measure mitochondrial respiration of permeabilized fibers. Samples were also analyzed for miR-210 expression by real-time PCR. MiR-210 expression was significantly elevated in IC and CLI muscle compared to CON (P=0.008 and P < 0.001, respectively). Mitochondrial respiration of electron transport chain (ETC) Complexes II (P=0.001) and IV (P < 0.001) were significantly reduced in IC patients. Further, CLI patients demonstrated significant reductions in respiration during Complexes I (state 2: P=0.04, state 3: P=0.003), combined I and II (P < 0.001), II (P < 0.001), and IV (P < 0.001). The expression of the miR-210 targets, cytochrome c oxidase assembly factor heme A: farnesyltransferase (COX10), and iron-sulfur cluster assembly enzyme (ISCU) were down-regulated in PAD muscle. MiR-210 may play a role in the cellular adaptation to hypoxia and may be involved in the metabolic myopathy associated with PAD.

Prognostic Factors and Predictors of Mortality in Patients with Critical Limb Ischemia: A Current Clinical Perspective

Critical limb ischemia (CLI) is an end-stage peripheral arterial disease (PAD). Mortality, limb loss, pain, and diminished health-related quality of life are highly prevalent in CLI patients. 20 to 50% CLI Mortality is intensely observed within the first six months to five years of CLI diagnosis, respectively. Prognostic treatments, including autologous bone marrow mononuclear cell implantation (BMMNCI), low-intensity pulsed ultrasound (LIPUS) technology, and medication therapy using Cilostazol, are available. In addition, required prognostic factors such as timely access to medical care can control the death. Impaired mobility, old age, low BMI, CKD (end-stage), T2DM, COPD (oxygen-dependent), HF, smoking, high Wound, Ischemia, and Foot Infection are the additional predictors for CLI-related mortality. Due to the poor survival and prognosis, it is crucial to identify the prognostic factors that will lead to better clinical benefits, including amputation-free survival rate and improved quality of life. This review highlights the current clinical perspective on the prognostic factors and predictors of mortality in CLI patients.

Endovascular treatment for critical limb ischemia in patients with diabetes mellitus: new opportunities and prospects

Diabetes mellitus (DM) is still one of the most common endocrine diseases despite all available technologies in modern medicine. In recent years, it was shown that severity and duration of DM are closely associated with vascular wall lesions (the called micro-and macroangiopathy). One of severe clinical signs is damage to lower limb arteries followed by trophic and purulent-necrotic lesions of soft tissues (diabetic foot syndrome) and risk of amputation. The authors review the possibilities of endovascular treatment of critical limb ischemia in patients with diabetes mellitus. The features of endovascular interventions depending on clinical and morphological peculiarities of vascular lesions are discussed. The authors compared the results of open and endovascular treatment of lower limb ischemia and determined further prospects for improving the treatment of these patients.

THE LIMFLOW SYSTEM FOR NO-OPTION CRITICAL LIMB ISCHEMIA (CLI) PATIENTS

Critical limb ischemia (CLI) is a common health problem among adults. CLI is a progressive type of peripheral artery disease associated with non-healing ulceration and ischemic pain at rest. Patients with CLI may suffer from gangrene, a consequence of arterial occlusive disease. Patients with CLI have a high-risk of developing chronic health issues such as hyperlipidemia, renal failure, hypertension, and diabetes mellitus. The health and well-being of patients with CLI is low and heterogeneously complex. Patients with CLI cope with complex and chronic health issues that often require appropriate treatment and management. The newly developed Limflow system is the promising future for vascular interventions in CLI patients.

Evaluation of Tissue Perfusion by Wound Blush and 2D Color-Coded Digital Subtraction Angiography During Endovascular Intervention and Its Impact on Limb Salvage in Critical Limb Ischemia

Purpose: Critical limb ischemia (CLI) is an entity with high mortality if not properly treated. The primary aim of CLI revascularization is to enhance wound healing, which greatly depends on microvascular circulation. The available tools for assessment of revascularization success are deficient in the evaluation of local microvascular tissue perfusion, that wound blush (WB) reflects. A reliable technique that assesses capillary flow to foot lesions is needed. This study aims to assess WB angiographically at sites of interest in the foot after revascularization and its impact on limb salvage in CLI. Materials and Methods: 198 CLI patients (Rutherford category 5/6) with infrainguinal atherosclerotic lesions amenable for endovascular revascularization (EVR) were included. Limbs were directly or indirectly revascularized by EVR. Direct revascularization meant that successful revascularization of the area of interest according to the angiosome concept was achieved. A completion angiographic run was taken to assess WB. Patients were divided into 2 groups; positive and negative WB groups. In the event of a disagreement between the observational investigators, the digital subtraction angiography (DSA) series was analyzed for hemodynamic changes with a computerized 2D color-coded DSA (Syngo iFlow). Results: 176 limbs had successful revascularization in 157 patients. The successful revascularization rate was 88.9% (176/198), with technical failure encountered in 22 limbs. 121 patients had positive WB and 55 patients had negative WB. Direct revascularization of target areas was obtained in 98 limbs (55.7%). There was a significant difference in the rate of achieving direct flow to the lesion between the positive WB and negative WB groups (36.4% vs 19.3%, p≤0.001). We noticed a nonsignificant difference between patients who had direct revascularization of the foot lesion(s) and those who had indirect revascularization as regards limb salvage. Patients were followed up for 25.2 ± 12.7 months. By the end of the first year, limb salvage rate was significantly higher in patients who had positive WB (98% vs 63%, p<0.001, after 2 years (97% vs 58%, p<0.001) and after 3 years (94% vs 51.5%, p<0.001). Conclusions: WB is an important predictor and a prognostic factor for wound healing in CLI patients with soft tissue lesions.

Abstract 12967: Deletion of G Protein-Coupled Receptor 39 Protects Angiogenesis in Hyperglycemia

Introduction: Endothelial cells (ECs) are essential to vascular homeostasis and angiogenesis. Endothelial dysfunction significantly contributes to critical limb ischemia in patients with diabetes. G protein-coupled receptor (GPR) 39 is an orphan receptor whose role in EC functions is unknown. We hypothesize that inhibition of GPR 39 protects angiogenesis under hyperglycemic conditions. Methods and Results: Healthy human aortic endothelial cells (H-HAECs) and diabetic human aortic endothelial cells (D-HAECs) were cultured in vitro . The migration (Modified Boyden Chamber assay) and tube formation capacity of H-HAECs were impaired by the transfection of adenovirus carrying human GPR39 or by a GPR39 agonist, TC-G-1008 (both n=5, p&lt;0.05). Conversely, GPR39 siRNA improved D-HAEC migration (n=4 per group, p&lt;0.05). In an angiogenesis protein profiler array, GPR39 overexpression has significantly reduced vascular endothelial growth factor (VEGF), Interleukin-8, monocyte Chemoattractant Protein-1 (MCP1), and Angiopoietin-2 in H-HAECs (n=5 per group, p&lt;0.05). Adult male GPR39 global knockout (GPR39 KO ) mice and age- and sex-matched wild-type (GPR39 WT ) litters were rendered diet-induced obese (DIO) by a 10-week high-fat and an add-on 8-week hyperglycemia by low-dose streptozotocin (STZ) injections chow as they reflect the human condition where obesity is closely linked to type 2 diabetes development. Hind limb ischemia was created by left femoral artery ligation. Laser Doppler imaging showed that GPR39 KO mice had a faster blood perfusion recovery from ischemia than GPR39 WT mice (n=5 per group, p&lt;0.05). In adult male C57BL/6 with DIO-STZ, intramuscular injection of EC-affinitive AAV-mediated shRNA against GPR39 significantly accelerated blood perfusion recovery and prevented tissue necrosis compared to empty AAV treatment (n=5 per group, p&lt;0.05). Conclusion: Our data indicated that genetic inhibition of GPR39 improved EC functions and accelerated angiogenesis from ischemia. We believe that the investigations in endothelial GPR39 may help better identify the novel therapeutic potential of targeting GPR39 in treating vascular complications in hyperglycemia.

Hybrid Revascularization for Aorto-Iliac Occlusive Disease with Common Femoral Artery Involvement: Early Outcomes of a Single Centre.

To study the early outcomes of aorto-iliac occlusive disease with common femoral artery involvement by hybrid methods of revascularization - iliac stenting with femoral endarterectomy. We report the initial experiences of a single centre and discuss issues that arose. Ninety-eight critical limb ischaemia (CLI) patients with aorto-iliac occlusive lesions TASC-II C and D were treated using HR between January 2017 and September 2020 in the Ivano-Frankivsk Regional Clinical Hospital. Prospective data were recorded and analysed including demographics, technical success, 30-day and early patency outcomes, re-intervention, and death. The mean age of patients was 65 ± 7.2 years (61 men and 37 women). Using classification by TASC-II, 77% of the lesions were class D. Technical success was seen in 98% of patients. Two patients underwent a crossover femoro-femoral bypass due to failure to re-enter the true lumen of the aorta during endovascular lesion crossing. There were no deaths during the 30-day period. No re-interventions for thrombosis were needed. Additional delayed bypass procedures were required in 19 patients (19.3%) with distal occlusions and minor and major tissue loss. The overall complication rate was 16.3% (16 patients). The 30-day patency rate was 100%. The median follow-up period was 18 months (range 1-36 months) with a primary patency rate of 87.2%, and cumulative primary assisted and secondary patency rate of 93.4%. Four patients died during the study period. Hybrid revascularization is a safe and less traumatic method of managing aorto-iliac occlusive disease with common femoral artery involvement. Good early patency results and low major complication rates indicate that HR is an excellent alternative to traditional open surgery, especially for high-risk patients.

Total thrombus-formation analysis system (T-TAS) can predict target lesion revascularization in patients undergoing endovascular therapy for critical limb ischemia

Abstract Background Despite of the development of endovascular therapy (EVT), the frequency of target lesion revascularization (TLR) after EVT in patients with critical limb ischemia (CLI) is still high. Recent histrogical study suggested the possibility of thromboembolic phenomenon in the development of CLI; however, there is few monitoring system of total thrombogenicity in perioperative period of EVT in CLI patients. The total thrombus-formation analysis system (T-TAS), a novel system for quantitatively analyzing thrombus formation using microchips with thrombogenic surfaces (collagen plus tissue factor, atheroma [AR]-chip), is validated and can evaluate the total thrombogenicity. Purpose To investigate the utility of T-TAS parameters in predicting TLR after EVT in CLI patients. Methods We analyzed 27 CLI patients (45 lesions; aortoiliac 20%, femoropopliteal 40%, infrapopliteal 40%) who underwent EVT at our institution between January 2018 and December 2020. Patients undergoing hemodialysis were excluded. Blood sample was collected on the day of EVT and was used in T-TAS to compute the thrombus formation area under the curve (AUC; AUC for the first 30 minutes for AR tested at flow rate of 10 lL/min [AR10-AUC30]). We investigated the relationship between the AR10-AUC30 level and the occurrence of clinically-driven TLR, and the predictors of TLR among CLI patients. Results Study population had a mean age of 77 years, and 56% were male. During the follow-up period (mean 1.0±0.7 years), 11 lesions (24%) required clinically-driven TLR. The AR10-AUC30 level was significantly higher in patients requiring TLR than those without TLR (1783±121 vs. 1587±205; p&amp;lt;0.01). The frequency of TLR significantly increased in association with a tertile of the AR10-AUC30 level (Figure 1, p for trend=0.003). As shown in Figure 2, univariate logistic regression analysis demonstrated male sex and the third tertile of the AR10-AUC30 level compared to its first or second tertiles were significantly associated with TLR in patients with CLI, whereas platelet count, PT-INR, APTT, and atherosclerotic risk factors including glycated hemoglobin, low-density lipoprotein cholesterol, and renal function were not. Multivariate logistic regression analysis also revealed that the AR10-AUC30 level ≥1707 (=its third tertile) as an independent predictor for TLR, even after adjusted by age and sex (OR=6.28, 95% CI=1.18–33.3, p=0.03). Conclusions In patients with CLI, the AR10-AUC30 level measured by the T-TAS may be a potential predictor to identify the high-risk patients requiring TLR after EVT. This finding suggests the hypercoagulability in CLI patients and that an anticoagulant agent following EVT may be useful in preventing a restenosis in CLI patients. Further study with a larger sample size is warranted to validate this finding. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Impact of high on-treatment platelet reactivity after angioplasty in patients with critical limb ischemia

ObjectivesDual antiplatelet therapy (DAPT) with aspirin and clopidogrel is standard of care in patients with peripheral artery disease (PAD) after percutaneous transluminal angioplasty (PTA). However, high on treatment platelet reactivity (HTPR) to DAPT is frequent and associated with major adverse limb events (MALE) in PAD patients. Nevertheless, association of MALE and HTPR in patients with critical limb ischemia (CLI) is not known. Moreover, comorbidities might confound response to antiplatelet medication further. Hence, in this trial we analyzed pharmacodynamic responses to DAPT and clinical events in CLI patients post PTA. MethodsIn this prospective single center pilot analysis, we included 71 CLI patients. Patients received DAPT after PTA. Antiplatelet effect were measured by light transmission aggregometry (LTA) and vasodilator-stimulated protein phosphorylation assay (VASP). MALE, major adverse cardiac and cerebrovascular events (MACCE) and BARC bleeding within 12 months follow-up were assessed. ResultsMean age of patients was 73.37 ± 7.36 years and 47 (66.2%) were male. Overall HTPR appeared in 46 patients (64.8%). MALE and MACCE showed no differences between patients with and patients without HTPR. However, bleeding was higher in patients with sufficient pharmacodynamic response to DAPT (Bleeding - HTPR: 13.4% vs. no HTPR: 36.0%; log-rank HR: 0.32; 95% CI 0.1079 to 0.9396 p = 0.0217). This finding remained robust in multivariate analysis. ConclusionHTPR to DAPT is frequent in CLI patients. However, bleeding was higher in patients with sufficient response to DAPT. Ischemic events did not differ. Hence, CLI patients might benefit from an alternative antithrombotic approach.

Endovascular Recanalization of the Chronically Occluded Native Superficial Artery After Failed Bypass Graft: Midterm Results

PurposeTo evaluate the safety, effectiveness, and outcomes of endovascular recanalization of chronic total occlusion (CTO) of the superficial femoral artery (SFA) in patients with critical limb ischemia (CLI) after failed surgical bypass graft. MethodsEndovascular recanalization of SFA CTO was performed for 26 consecutive CLI patients with failed bypass grafts from 2016 to 2020. Patient demographics, bypass and lesion characteristics, procedural data, technical, and clinical outcomes were evaluated. ResultsThe technical success rate was 96.2% (25/26). Retrograde arterial access was used in 16 (61.6%) patients. Additional tibial and iliac angioplasty was performed in 15 and 2 patients, respectively. Fifteen complications occurred in 10 patients, including thrombosis, embolism, vessel rupture, dissection, arteriovenous fistula, and pseudoaneurysm. Pain relief and wound healing were achieved in 22 patients. The primary, assisted primary, and secondary patency rates were 95.5%, 100%, and 100% at 6 months, 81.8%, 95.5%, and 100% at 12 months, and 76.7%, 82.7%, and 87.5% at 24 months, respectively. By univariate analysis, hyperlipidemia (hazard ratio = 7.82; 95% CI: 1.27–48.04, P = .026) was found to be the only significant risk factor related to primary patency loss. Amputation-free survival and limb salvage rates were 100% and 100% at 6 months, 100% and 100% at 12 months, and 87.1% and 93.8% at 24 months, respectively. ConclusionsEndovascular recanalization of SFA CTO in CLI patients with graft failures is effective with high technical success rates. Acceptable limb salvage and amputation-free survival rates make this technique a reasonable alternative to repeat surgery for high-risk patients.

Endothelial function in patients with critical and non-critical limb ischemia undergoing endovascular treatment.

Critical limb ischemia (CLI) is the most advanced stage of peripheral arterial disease. CLI patients, compared to non-CLI, achieve worse treatment outcomes and generate higher costs. The aim of the study was to compare endothelial function and clinical outcomes in CLI and non-CLI patients after percutaneous transluminal angioplasty (PTA). In this prospective, follow-up study, 30 CLI patients and 40 non-CLI patients underwent PTA. Endothelial function was assessed based on flow mediated dilatation (FMD), reactive-hyperemia index (RHI), while the ankle-brachial index, toe-brachial index and the Rutherford scale were used for peripheral artery disease progression evaluation. The results were assessed before PTA, as well as 1, 3, 6 and 12 months after the procedure. There were no differences at the baseline regarding to endothelial function between both groups. Neither FMD nor RHI changed after PTA in any of the groups, although there was a difference in median RHI value between CLI and non-CLI patients regarding the 1st and 6th month of the follow-up (RHI6-RHI1 = 0.08 in CLI and -0.15 in non-CLI; P = 0.01). The larger baseline intima-media thickness (IMT) in the CLI group allowed to predict a greater number of re-intervention (P = 0.01) and major adverse event rates (P = 0.03). CLI patients presented larger decrease in the Rutherford scale compared to non-CLI (P <0.001). Baseline IMT was predictive for re-interventions and major adverse event rates. Although neither of groups exhibited significant changes in endothelial function, we proved differences between them regarding to changes in RHI.